Developmental Stages: End-of-Life Care

A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which should the nurse implement?

✅Close the deceased client's eyes and place gauze and a small ice pack on the eyes. Rationale: When a corneal donation is anticipated, the client's eyes are closed and gauze pads with a small ice pack are placed on the client's eyes. The head of the bed should be elevated. Antibiotic eye drops also may be prescribed. These actions will assist in preventing infection and edema. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. It is unnecessary to obtain the client's will. Dry dressings should not be applied over the eyes. Calling the National Eye Bank to confirm that the client is a donor will delay necessary and immediate intervention.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

✅Encourage expression of feelings, concerns, and fears. ✅Touch and hold the client's or family member's hand if appropriate. ✅Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

A client's spouse becomes distraught when thinking about his wife's terminal prognosis. Which action should the nurse implement to promote hope for the spouse?

✅Encourage formation of achievable goals. Rationale: The nurse assists the spouse in developing realistic, achievable goals to promote the contextual dimension of hope. Promoting the reality of loss helps facilitate mourning. To promote the affiliated aspects of hope, the nurse encourages the spouse or client to cultivate helpful, caring relationships. The nurse encourages the expression of positive and negative goals in empathetic understanding to promote the affective dimension.

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measures to alleviate the spouse's distress? Select all that apply.

✅Engage the spouse in providing comfort. ✅Encourage the spouse and client to hold hands. Rationale: The most effective method of alleviating the spouse's distress is to provide comfort for both individuals. By helping the spouse comfort the client, the spouse helps alleviate the client's discomfort and thus helps attenuate his own distress. This is because providing comfort to the client gives the spouse a sense of purpose, control, and value. The nurse should encourage the couple to maintain intimacy. The remaining options are reasonable nursing interventions in palliative care; conveying respect helps maintain dignity and self-esteem, promoting therapeutic communication is important in establishing a caring relationship, and maintaining a presence helps prevent feelings of abandonment and isolation. Discouraging the spouse and client from talking about the illness discourages communication and will not alleviate distress.

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply.

✅He expresses his anger at God and the primary health care providers for allowing this to happen. ✅He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. ✅He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites. Rationale: The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, the dying person, God or other spiritual being, or the caregivers. The expected responses by the husband are expressing anger at God, bargaining for more time, and making funeral arrangements. These actions indicate progression through the Kubler-Ross stages of dying. The options mentioning not allowing his wife to die at home and having children live with out-of-state relatives indicate possibly rash and unilateral decisions without taking into consideration anyone else's feelings. Not visiting his wife at the hospital is strong evidence of denial, as he refuses to see or discuss his wife.

The nurse is caring for a client at the end of life. Which late cardiovascular and respiratory findings should the nurse expect to note while collecting data? Select all that apply.

✅Irregular heart rate ✅Decreased pulse rate ✅Decreased blood pressure ✅Irregular breathing patterns Rationale: The heart is one of the main organs for perfusion, and the lungs are the main organ for gas exchange. When death nears, the pulse will first increase, and then decrease and weaken. The heart will beat irregularly, causing a decrease in blood pressure. In addition, irregular breathing, gradually slowing down to terminal gasps, occurs. A friction rub is a sign of inflammation of the lining of the heart and is not a sign noted at the end of life.

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?

✅Irregular, noisy breathing and cold, clammy skin. Rationale: The clinical signs of impending or approaching death include inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?

✅Maintain the client's dignity and self-esteem, and make the client as comfortable as possible. Rationale: The nurse needs to focus on the needs of the client, keep the client comfortable, and maintain dignity and self-esteem. Although the nurse needs to control the pain, it is not necessary to keep the client sedated so that the client is totally unaware of what is happening. The client should be able to interact with family members and make care decisions. Family needs are important, but the client's needs are most important. Prescribed treatment needs to be carried out, but making the client comfortable and maintaining dignity are priorities.

The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate that death is approaching? Select all that apply.

✅Nausea ✅Incontinence ✅Accumulation of gas ✅Abdominal distention Rationale: As death approaches, the client may experience nausea, loss of sphincter control resulting in incontinence, an accumulation of gas, and abdominal distention. Diarrhea is not common because slowing or cessation of gastrointestinal function occurs, which also may be enhanced by pain-relieving medications.

A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. The nurse realizes this action corresponds to which aspect of grieving?

✅Normal grieving. Rationale: A perinatal bereavement support group can help the parents work through their pain by non-judgmental sharing of feelings. It is a necessary part of normal grieving. The client and her husband are not indicating anger, denial, or prolonged sadness.

The nurse is caring for an 8-year-old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices that the child has a dry mouth and the family believes the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions should the nurse take? Select all that apply.

✅Perform frequent oral care with mouth swabs. ✅Encourage the family to participate in oral care as much as desired. ✅Give the child small sips of water or ice chips if alert and requested by the child. Rationale: Oral care should be performed regularly to promote comfort and prevent complications. Mouth swabs should be used to provide moisture or to administer analgesics. Giving the child mouthwash is not appropriate because this is not helpful, especially if the child is too weak to perform self-care and do his or her own mouth care. In addition, this action places the semiconscious child at risk for aspiration. If requested by the child, ice chips or small sips of water can be given. If fluids are provided to the child, only small amounts should be given to prevent choking. Family participation in oral care allows for bonding time with the child. Oral intake decreases at the end of life.

A licensed practical nurse (LPN) is providing instructions to an unlicensed assistive personnel (UAP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the UAP performs which action?

✅Places a dry sterile dressing over the open eyes. Rationale: When a corneal donor dies, the eyes are closed and gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated. Option 3 would be an incorrect action by the UAP.

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions should the nurse take to provide end-of-life psychological care? Select all that apply.

✅Provide privacy to the client and family. ✅Encourage the family to talk with and reassure the client. ✅Encourage visits by appropriate spiritual services as desired. Rationale: When caring for a client at the end of life who is experiencing agitation and visual hallucinations, it is important to provide privacy and to encourage the family to talk with and reassure the client to alleviate agitation. The nurse should also provide access to spiritual services such as pastors or chaplains if desired. The nurse should speak directly to the client in a soft tone of voice, especially when the client appears withdrawn. It is not necessary to avoid taking in the presence of the client; in fact, conversation should be encouraged.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

✅Remain with the family member without discussing funeral arrangements. Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions should be included? Select all that apply.

✅Respond to requests from the client and family promptly. ✅Support the client's decision-making in order to promote client control. ✅Provide information about what to expect during the dying process to the client and family. Rationale: When creating a care plan for a client at the end of life, it is important to include the client and family in the decision-making. Responses to requests from the client and family should be done promptly, and supporting the client in their decision-making will assist the client in remaining in control. The nurse should also keep the client and family informed of the dying process to alleviate stress and anxiety. Individualize care plans rather than standardized care plans should be used for the client that is dying, and the nurse should allow as much time as needed when communicating with the client and family.

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

✅The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands. Rationale: Making decisions for the client and family removes autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention that can further impair communication. Encouraging discussion of feelings is likely to enhance communication and would not require further assistance. Because spiritual practices give meaning to life and have an effect on how people react to crisis, no further assistance is required. The client and family need to know that someone will be supportive and nonjudgmental; this would not require further assistance.

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply.

✅Time and date of death. ✅Time of body transfer and destination. ✅Medical tubes, devices, or lines left in the body. ✅Name of primary health care provider certifying death. Rationale: Proper documentation of postmortem care, or care of the body after death, is required. Agency policies and procedures are always followed to provide an accurate and reliable medical record of all activities and assessments surrounding a death. Time and date of death and all actions taken to respond to the impending death; time of body transfer and destination; the name of the certifying primary health care provider; persons notified of the death; and any medical tubes, devices, or lines left in the body are some of the essential aspects that should be documented. Documentation of present family members is not required.

The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note? Select all that apply.

✅Waxlike texture. ✅Mottling of arms, legs, hands, and feet. ✅Cyanosis of the nose, nail beds, and knees. Rationale: At the end of life, the skin loses elasticity and therefore has a waxlike texture. Decreased perfusion will cause mottling and cyanosis of the skin, nose, and nail beds. Skin will become cool and clammy, not warm or dry, as death approaches.