Mental Health Chapter 30 - Dying, Death, and Grieving

As a terminally ill patient becomes less able to take in sustenance, what is the most important information for the nurse to share with the family? "We will start giving intravenous fluids to stave off dehydration." "Difficulty taking in water or food means the illness is progressing." "Dehydration is a common cause of death in terminally ill patients." "Lack of food is a common cause of death in terminally ill patients."

"Difficulty taking in water or food means the illness is progressing." As a terminally ill patient becomes less able to take in sustenance, one important distinction to keep in mind is that the patient is not dying of dehydration or lack of food but rather from the illness. The nurse should encourage families to offer water orally rather than intravenously as often as their actively dying loved one desires and is able to swallow. Dehydration and a lack of food are not the causes of death in terminally ill patients. As a terminally ill patient becomes less able to take in sustenance, what is the most important information for the nurse to share with the family?1"We will start giving intravenous fluids to stave off dehydration."2"Difficulty taking in water or food means the illness is progressing."3"Dehydration is a common cause of death in terminally ill patients."4"Lack of food is a common cause of death in terminally ill patients."

Which question asked by the nurse demonstrates attention to the primary concern of palliative care? "Has your pain medication been effective at keeping you comfortable"? "Do you want to receive your palliative care at home or in an institutional setting?" "Do you have a spiritual provider you want me to be contacted?" "Who will be your acting as your primary care provider?"

"Has your pain medication been effective at keeping you comfortable"? Excellent symptom management is a hallmark of palliative nursing. Assessing pain management would reflect such a concern. While the other options present appropriate assessment questions, they do not address the primary issue of palliative care. REF: 554

Which statements identify a client's progress through the stages of grief? Select all that apply. "He didn't die; I'm sure he will be found and be just fine." "I will never accept he's gone; I will never give up looking for him." "If they find him, I'll never doubt miracles again." "I'll never understand why he risked his life by hitchhiking at night." "Knowing he's gone makes me so sad."

"He didn't die; I'm sure he will be found and be just fine." "If they find him, I'll never doubt miracles again." "I'll never understand why he risked his life by hitchhiking at night." "Knowing he's gone makes me so sad." The five stages of grief identified by Kübler-Ross include denial, anger, bargaining, depression, and acceptance. The statement concerning never giving up demonstrates the inability to accept the individual's death.DIF: Cognitive Level: Analyze (Analysis)REF: page 3TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity

The nurse is talking to the family of a patient who died suddenly and unexpectedly. What is the most appropriate statement by the nurse? "Your loved one is with God now." "At least your loved one didn't suffer." "I know how hard it is to lose your loved one." "It must be shocking to lose your loved one so suddenly."

"It must be shocking to lose your loved one so suddenly." The most appropriate statement by the nurse is, "It must be shocking to lose your loved one so suddenly." The nurse should not assume the grieving family believes in God. "At least your loved one didn't suffer" suggests the lack of suffering minimizes the trauma of the loss. The nurse cannot really know what the grieving family is feeling, and the focus should remain on the patient's family.

Which assessment question best demonstrates the nurse's understanding of a dying client's needs? "What are your hopes for your final days?" "Have you completed a Living Will?" "Are you aware of the pain control options available?" "Do you have any concerns about paying for your end-of-life care?"

"What are your hopes for your final days?" Care of the dying is a nursing responsibility. The focus of this care needs to shift toward the question, "What do you hope for at the end of your life?" rather than managing the cost of medical care. Pain management and advance directives are only individual aspects of end of life care. DIF: Cognitive Level: Analyze (Analysis)REF: page 4TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

In adults, grief is considered to be persistent if it lasts longer than how many months? 2 4 6 12

12 In adults, grief is considered to be persistent if it lasts longer than 12 months. Grief lasting 2 or 4 months is not considered persistent. In children, grief is considered to be persistent if it lasts longer than 6 months.

In children, grief is considered to be persistent if it lasts longer than how many months? 2 4 6 12

6 In children, grief is considered to be persistent if it lasts longer than 6 months. Grief lasting 2 or 4 months in adults or children not considered to be persistent. In adults, grief is considered to be persistent if it lasts longer than 12 months.

Which criterion must be met in order for a patient to be eligible for hospice care? The patient must be age 65 years or older. The patient must demonstrate financial need. The patient's diagnosis cannot be related to substance abuse. A physician must certify the patient with a life expectancy of 6 months or less.

A physician must certify the patient with a life expectancy of 6 months or less. In order to be eligible for hospice care, a physician must certify the patient with a life expectancy of 6 months or less. Hospice care supports and cares for patients facing death regardless of age, income, or diagnosis.

A patient with a new diagnosis of cancer says, "My father died of pancreatic cancer. I took care of him during his illness, so I know what is ahead for me." Which nursing diagnosis applies? a. Anticipatory grieving b. Ineffective coping c. Ineffective denial d. Spiritual distress

ANS: A The patient's experience demonstrates anticipatory grieving. The other diagnoses may apply but are not supported by the comment.

A terminally ill patient says, "I know I will never get well, but," and the patient's voice trails off. Select the most therapeutic response by the nurse. a. "What do you hope for?" b. "Do you have questions about what is happening?" c. "You are not going to get well. It is healthy that you accept that." d. "When you have questions, it is best to talk to the health care provider."

ANS: A This open-ended response is an example of following the patient's lead. It provides an opportunity for the patient to speak about whatever is on his mind. The distracters are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's most therapeutic action. a. Say, "I understand you are feeling upset. I will stay with you until your family comes." b. Say, "Your husband's heart was so severely damaged that it could no longer pump." c. Say, "I will call my supervisor to discuss this matter with you." d. Hold the spouse's hand in silence until the family arrives.

ANS: A When bereaved family behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating. Touch (holding hands) is culturally defined; it may or may not be appropriate in this situation.

Family members ask the nurse, "What can we say when our loved one says, 'Death is coming soon?'" To promote communication, which response could the nurse suggest for family members? a. "We feel sad when we think about life without you." b. "We have not given up on getting you well." c. "We think you will be around for a long time yet." d. "Let's talk about the good memories we have."

ANS: A The correct response is emotionally honest. It allows the family opportunities to express emotions, address issues in the relationship, and say farewell. The distracters are evasive.

Which patients meet criteria for hospice services? (Select all that apply.) a. A 92-year-old diagnosed with acute pneumonia and late-stage Alzheimer's disease b. A 54-year-old diagnosed with glioblastoma and life expectancy of 8 to 10 weeks c. A 16-year-old with type 1 diabetes, multiple infections, and substance abuse d. A 74-year-old newly diagnosed with chronic obstructive pulmonary disease (COPD) and life expectancy of 2 years e. A 36-year-old diagnosed with multiple sclerosis complicated by major depressive disorder and pain associated with muscle spasms

ANS: A, B Hospice services are available to patients with terminal illnesses and a life expectancy of less than 6 months. The patient must choose hospice care, rather than curative treatments. Although patients with other health problems may experience complications, treatments focusing on cure would exclude them from hospice services.

Which actions by a nurse are most appropriate when caring for a hospice patient? (Select all that apply.) a. Giving choices b. Fostering personal control c. Explaining curative options d. Supporting the patient's spirituality e. Offering interventions that convey respect f. Providing answers to the patient's questions about spirituality

ANS: A, B, D, E The correct answers support the rights and choices of the dying individual. Acting on false information robs a patient of the opportunity for honest dialogue and places barriers to achieving end-of-life developmental opportunities. The nurse supports the patient's spirituality but does not have the answers to all questions.

A staff nurse asks a hospice nurse, "Who should be referred for hospice care?" Select the best response. a. "Hospice is for terminally ill patients diagnosed with cancer." b. "Patients in the end stage of any disease are eligible for hospice." c. "Hospice is designed to care for patients experiencing end-stage renal disease." d. "Patients diagnosed with degenerative neurological diseases are eligible for hospice after paralysis occurs."

ANS: B A hospice service cares for terminally ill patients regardless of diagnosis.

After the death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

ANS: B A statement that validates the bereaved person's loss is more helpful than commonplace clichés. It signifies understanding. The other options are clichés.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." Which analysis applies? a. The comment warns of a malpractice suit. b. Anger is a phenomenon experienced during grief. c. The wife had conflicted feelings about her husband. d. In some cultures, grief is expressed solely through anger.

ANS: B Anger may be manifested toward the health care system, God, or even the deceased. Anger may protect the bereaved from facing the devastating reality of loss. Anger expressed during mourning is not directed toward the nurse personally, even though accusations and blame may make him/her feel as though it is.

Which event is most likely to precipitate grief across a community? a. A local bank is robbed twice in a single month b. An adolescent shoots the principal of a local high school c. The elderly pastor of the town's largest church dies of heart failure d. Concrete pilings crumble in a bridge important to movement of local traffic

ANS: B The correct response identifies an event likely to be perceived as a public tragedy. The distracters are occurrences that are more commonplace. They may precipitate concern but not grief

Which finding indicates successful completion of an individual's grief and mourning? a. For 2 years after her husband's death, a widow has kept her husband's belongings in their usual places. b. After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife. c. Three years after her husband's death, the widow talks about her husband as if he is alive and weeps when others mention his name. d. Eighteen months after a spouse's death, an adult says, "I have never cried or had feelings of loss, even though we were very close."

ANS: B The goals of mourning have evolved from doing the grief work, getting over it, and moving on with life. The work of grieving is over when the bereaved person can remember the individual realistically and acknowledge both the pleasure and disappointments associated with the loved one. The individual is then free to enter into new relationships and activities. The incorrect options suggest maladaptive grief.

A patient with pancreatic cancer says, "I know I am dying, but I am still alive. I want to be in control as long as I can." Which reply by the nurse shows active listening? a. "Our staff will do their best to manage your pain." b. "Your mind and spirit are healthy, although your body is frail." c. "It's important for you to let others help you to ease their own pain." d. "Are you saying you want people to stop focusing on your diagnosis?"

ANS: B The patient has strengths and capabilities and is asking for acknowledgment that he/she is not incapacitated, even though the diagnosis is likely terminal. The correct answer provides that acknowledgment. The other responses are tangential.

As death approaches, a patient diagnosed with AIDS says, "I do not have enough energy for many visitors anymore and I am embarrassed about how I look. I only want to see my parents and sister." Which actions should the nurse take? (Select all that apply.) a. Encourage the patient to reconsider this decision so that interested and caring friends can provide support. b. Support the patient to share the request with the parents and sister. c. Assist family to inform the patient's friends of the request. d. Suggest that the patient discuss these wishes with clergy. e. Place a "No Visitors" sign on the patient's door.

ANS: B, C The correct responses empower the patient to maintain dignity, control, personal space, and confidentiality. As some patients approach death, they begin to withdraw. In the stage of acceptance, many patients are exhausted and tired, and interactions of a social nature are a burden. Many prefer to have someone present at the bedside who will sit without talking constantly.

One month ago, an adult died from cancer. Family members now gather at the adult's home to dispose of the deceased's belongings. Which comments demonstrate the family member is coping with the loss in an effective way? (Select all that apply.) a. "Her possessions still have her scent. We should dispose of them." b. "Let's take turns selecting items of hers we would each like to have." c. "When I die, I hope someone who loved me goes through my things." d. "This was her favorite jacket. If we donate it to charity, someone else can enjoy it too." e. "We're violating her privacy by looking through her things. Let's call a charity to come pick up everything."

ANS: B, C, D

A nurse talks with a woman who recently learned that her husband died while jogging. Select the appropriate statement for the nurse. a. "At least your husband did not suffer." b. "It's better to go quickly as your husband did." c. "Your husband's loss must be very painful for you." d. "You will begin to feel better after you get over the shock."

ANS: C The most helpful responses by others validate the bereaved person's experience of loss. Avoid clichés, because they are ineffective.

A patient who was widowed 18 months ago says, "I can remember good times we had without getting upset. Sometimes I even think about the disappointments. I am still trying to become accustomed to sleeping in the bed all alone." The work of mourning a. is beginning. b. has not begun. c. is at or near completion. d. is progressing abnormally.

ANS: C The work of mourning has been successfully completed when the bereaved can acknowledge both positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

A widow repeatedly tells details of finding her elderly husband not breathing, performing cardiopulmonary resuscitation, and seeing him pronounced dead. Family members are concerned and ask, "What can we do?" The nurse should counsel the family that a. they should express their feelings to the widow and ask her not to retell the story. b. the retelling should be limited to once daily to avoid unnecessary stimulation. c. repeating the story and her feelings is a helpful and necessary part of grieving. d. retelling of memories is expected as part of the aging process.

ANS: C Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy because repetition is a helpful and necessary part of grieving.

A widower tells friends, "I am taking my neighbor out for dinner. It's time for me to be more sociable again." Considering the stages of grief described by Kübler-Ross, which stage is evident? a. Anger b. Denial c. Depression d. Acceptance

ANS: D As an individual accepts loss, the person renews interest in people and activities. The person is seeking to move into new relationships. The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also experience occasional anger or sadness, the comment speaks directly to acceptance.

After a spouse's death, an adult repeatedly says, "I should have recognized what was happening and been more helpful." This adult is experiencing a. depression. b. bargaining. c. anger. d. guilt.

ANS: D Guilt is expressed by the bereaved person's self-reproach. Anger, depression, and bargaining cannot be assessed from data given in the scenario.

A child drowned while swimming in a local lake 2 years ago. Which behavior best indicates the child's parents are mourning in an effective way? The parents a. forbid their other children from going swimming. b. keep a place set for the deceased child at the family dinner table. c. sealed their child's room exactly as the child left it 2 years ago. d. throw flowers on the lake at each anniversary date of the accident.

ANS: D Loss of a child is among the highest risk situations for maladaptive grieving. Depending on many factors, this process can take many months to a number of years. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The incorrect options indicate the parents are isolating themselves and/or denying their feelings.

Four teenagers died in an automobile accident. Six months later, which behavior by the parents best demonstrates acceptance of the tragedy? The parents who a. isolate themselves at home. b. return immediately to employment. c. forbid other teens in the household to drive a car. d. create a scholarship fund at their child's high school.

ANS: D Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings.

A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you hearing voices at night?" b. "I am worried about how much you are crying. Your grief over your husband's death has gone on too long." c. "This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program." d. "The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings."

ANS: D The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for dysfunctional grieving because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. The crying 2 weeks after his death is expected and normal.

A hospice patient tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity and always gave my best. I intend to die as I lived." The nurse planning care for this patient would recognize the importance of a. providing aggressive pain and symptom management. b. helping the patient reassess and explore existing conflicts. c. assisting the patient to focus on the meaning in life and death. d. supporting the patient's use of own resources to meet challenges.

ANS: D The patient whose intrinsic strength and endurance have been a hallmark often wishes to approach dying by staying optimistic and in control. Helping such patients use their own resources to meet challenges would be appropriate.

An adult says to the nurse, "The cancer in my neck spread in only 2 months. I've been cursed my whole life. Maybe if I had been more generous with others ..." Considering the stages of grief described by Kübler-Ross, which stage is evident? a. Anger b. Denial c. Depression d. Bargaining

ANS: D The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also be experiencing anger and depression, the comment speaks directly to bargaining. The person shows acceptance of the disease.

The nurse is caring for a patient with a diagnosis of a terminal illness. The patient doesn't talk much and asks the nurse to refrain from allowing visitors. The family expresses concern to the nurse that the patient has given up. The nurse explains to the family that the patient is most likely experiencing which phase of the Kubler-Ross model? Anger Bargaining Acceptance Denial and isolation

Acceptance During the acceptance phase, the patient may wish for solitude and may not be as talkative. This phase can be notably difficult for loved ones of the patient, as they may not have accepted the impending loss and view the patient's ambivalence about impending death, as "giving up." In the anger phase, the patient becomes pessimistic and unhappy and may ask questions such as, "Why me? Why not someone else?" In the bargaining phase, patients may secretly try to make deals with a higher power to prolong their lives. The denial and isolation phase is typically a brief reaction in which the patient is in disbelief or shock about his or her situation. This phase can result in the patient seeking advice from other specialists in hopes that the diagnosis will indeed be a mistake.

Which written document states how a patient wants medical decisions to be made and what sort of life-prolonging measures should be taken if there's no hope for recovery? Dying will Individual liberty Informed consent Advance directive

Advance directive An advance directive is the written document that states how a patient wants medical decisions to be made and what sort of life-prolonging measures should be taken if there's no hope for recovery. This document is also called a living will, not a dying will. Individual liberty is the right of patients to refuse or withdraw treatment. Informed consent involves giving patients information about the possible risks and benefits of treatment before they grant permission to receive it.

Which issue should the nurse discuss when planning end-of-life care for a terminal ill client? Select all that apply. Advance directive planning Hospice admission Cost of needed services Symptom management Curative therapies

Advance directive planning Hospice admission Symptom management Patients often turn to their nurse for assistance in understanding how to make end-of-life decisions. Appropriate topics include advance directive planning, hospice admission, and symptom management including pain medication. The discussion of financial issues should be referred to social services or a personal finance advisor. Curative therapies are not considered when the client has been identified as having a terminal diagnosis. REF: 557

Which form of grief involves concerns for the future? Disenfranchised Dysfunctional Anticipatory Maladaptive

Anticipatory Anticipatory grief or anticipatory mourning is when a future loss is being mourned in advance. None of the other options are associated with premature mourning for a loss that is likely to occur in the future. REF: 558

Which is an example of an event that may cause grief as a result of public tragedy? Stillborn child Sudden death of a parent Assassination of a president Death resulting from a violent crime

Assassination of a president Public tragedies involve a loss with an impact that is felt broadly across a community or the general public. Entire communities and nations are shocked by genocide, war, assassinations, natural disasters, and school shootings. A stillborn child, death of a parent, and death resulting from violent crime do not specifically indicate public tragedy.

A client who has recently received a terminal cancer diagnosis has expressed the desire to, "stay out of the hospital and die at home." Which nursing intervention will best help the client achieve this end-of-life goal? Involving the client and his/her family in treatment decisions Encouraging adherence to the medical treatment plan Discussing available pain control measures Assistance with advance care planning

Assistance with advance care planning Advance care planning has helped patients and their families achieve end-of-life goals, avoid hospitalization, and increase hospice and palliative care use. While the other options are appropriate interventions, none are as focused on assuring the client's end-of-life goals that are documented supporting their achievement. DIF: Cognitive Level: Analyze (Analysis)REF: page 7TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

Which intervention demonstrates the fulfillment of a moral duty a nurse has to a dying patient? Treating the client respectfully Advocating for the client's right to privacy Assuring the client has the information needed for informed consent Assisting the client in determining their preferences and goals for care

Assisting the client in determining their preferences and goals for care According to the American Nurses Association's Code of Ethics nurses have a moral duty to help patients determine these preferences and goals at the end of life. The remaining options relate to compliance with client rights. REF: 557

In which phase of the Kübler-Ross model is the patient attempting to deal with overwhelming feelings of vulnerability and helplessness? Anger Bargaining Acceptance Denial and isolation

Bargaining In the bargaining phase, as the patient attempts to deal with overwhelming feelings of vulnerability and helplessness, he or she may secretly try to make deals with a higher power to prolong his or her life. The anger phase typically surfaces when the patient is ready to come to terms with the fact that he or she is in fact seriously ill and becomes pessimistic and unhappy. The acceptance phase is a final time for resting, free of pain and struggle. The patient may wish for solitude and may not be as talkative. Denial is typically a brief reaction in which the patient is in disbelief or shock about the situation.

Following the death of a loved one, what term describes the period after a death for those who have experienced the loss? Grief Mourning Depression Bereavement

Bereavement Bereavement, derived from the Old English word berafian meaning, "to rob," is the period of grieving after a death. Following the death of a loved one, a person's reaction to the loss is grief. Mourning refers to things people do to cope with grief including shared social expressions of grief such as viewing hours, funerals, and bereavement groups. A diagnosis of clinical depression should be carefully distinguished from characteristics of the normal grieving process.

The death of which terminal ill client, who self-administered a lethal dose of medication, resulted in the state of California adopting a Right to Die law? Terri Schiavo Jack Kevorkian Karen Anne Quinlan Brittany Maynard

Brittany Maynard Brittany Maynard was diagnosed with inoperable brain cancer in January of 2014. She and her husband moved from their home state of California to Oregon so that she could participate in Oregon's Death with Dignity Act. On November 1, 2014, Brittany self-administered a lethal dose of medication obtained under Oregon law. After Brittany's death, California Governor Jerry Brown signed a right to die bill into law. While all the other options identify individuals that played a role in the campaign to legalize physician-assisted suicide, none of their deaths resulted in California's adoption of a right to die law. REF: 566

Which term describes emotional connection, which the terminally ill patient may experience as he or she accepts the finality of life? Cathexis Cachexia Decubitus Decathexis

Cathexis Cathexis describes emotional connection, which the terminally ill patient may experience as he or she accepts the finality of life. Decathexis describes emotional withdrawal, which the terminally ill patient may experience as he or she accepts the finality of life. Cachexia describes severe weight loss, also known as wasting syndrome. Patients confined to bed may have decubitus ulcers, also known as bedsores.

In a persistent vegetative state, damage to what part of the brain eliminates cognitive function? Cortex Hypothalamus Medullary brainstem Reticular activating system

Cortex In a persistent vegetative state, the cortex is severely damaged, eliminating cognitive function. The hypothalamus and medullary brainstem remain intact to support cardiorespiratory and autonomic functions. The reticular activating system remains functional, making wakefulness possible.

What term describes emotional withdrawal, which the terminally ill patient may experience as he or she accepts the finality of life? Cathexis Cachexia Decubitus Decathexis

Decathexis Decathexis describes emotional withdrawal, which the terminally ill patient may experience as he or she accepts the finality of life. Cathexis describes an emotional connection, which the terminally ill patient may experience as he or she accepts the finality of life. Cachexia describes severe weight loss, also known as wasting syndrome. Patients confined to bed may have decubitus ulcers, also known as bedsores.

What may low scores on the Marwit-Meuser Caregiver Grief Inventory indicate? Select all that apply. High suicide risk Severe dementia Denial of distress Positive adaptation Need for intervention and formal support

Denial of distress Positive adaptation The Marwit-Meuser Caregiver Grief Inventory is a tool developed to identify the unique forms of grief experienced by caregivers of those with dementia. Low scores indicate either denial of distress or positive adaptation. This tool does not measure suicide risk or severity of dementia. High scores may indicate a need for intervention and formal support.

What type of grief occurs when the mourner does not have the opportunity to publicly grieve the loss? Acute grief Complex grief Persistent grief Disenfranchised grief

Disenfranchised grief Disenfranchised grief occurs when the mourner does not have the opportunity to publicly grieve the loss because the individual experiences intense loss that is not congruent with a socially recognized relationship. Examples are a lover, a divorced spouse, a caregiver, an abortion, or a pet. This could also include the grief felt by healthcare workers over the loss of a patient. Acute grief, complex grief, and persistent grief are not specific to this type of relationship. p. 562

According to the dual process model of coping, following the death of a loved one, which processes are restoration oriented? Select all that apply. Grief work Breaking bonds Distracting from grief Attending to life changes Avoiding restoration changes

Distracting from work Attending to life changes According to the dual process model of coping, distracting from grief and attending to life changes are restoration-oriented processes. Loss-oriented process include grief work, breaking bonds, and avoiding restoration changes.

What role should the nurse play in supporting patients making end-of-life care decisions? Encouraging patients to complete paperwork to support their wishes Making decisions for the patient based on the nurse's professional opinion Suggesting patients avoid discussing these matters with family to limit stress Explaining that the nurse may not take part in discussing end-of-life care without an attorney present

Encouraging patients to complete paperwork to support their wishes Encouraging patients to talk about end-of-life issues and complete paperwork to support their wishes is an important intervention for basic-level registered nurses. The nurse should not make these decisions for the patient or suggest patients avoid discussing these matters with family. Having an attorney present is not required when having these discussions.

Which argument for physician-assisted suicide represents the concept of autonomy? Patients have the right to refuse or withdraw treatment. Assisted suicide enhances the opportunity for excellent end-of-life care for all patients. Every competent person has the right to make momentous decisions based on personal convictions. The government has the constitutional power to override certain rights to protect citizens from irrevocable acts.

Every competent person has the right to make momentous decisions based on personal convictions. The autonomy argument for assisted suicide is represented by the statement that every competent person has the right to make momentous decisions based on personal convictions. The individual liberty argument for assisted suicide is represented by the statement that patients have the right to refuse or withdraw treatment. The quality of care argument for assisted suicide is represented by the statement that assisted suicide enhances the opportunity for excellent end-of-life care for all patients. The statement that the government has the constitutional power to override certain rights to protect citizens from irrevocable acts counters the individual liberty argument.

Which argument for physician-assisted suicide represents the concept of autonomy? Patients have the right to refuse or withdraw treatment Assisted suicide enhances the opportunity for excellent end-of-life care for all patients. Every competent person has the right to make momentous decisions based on personal convictions. The government has the constitutional power to override certain rights to protect citizens from irrevocable acts.

Every competent person has the right to make momentous decisions based on personal convictions. The autonomy argument for assisted suicide is represented by the statement that every competent person has the right to make momentous decisions based on personal convictions. The individual liberty argument for assisted suicide is represented by the statement that patients have the right to refuse or withdraw treatment. The quality of care argument for assisted suicide is represented by the statement that assisted suicide enhances the opportunity for excellent end-of-life care for all patients. The statement that the government has the constitutional power to override certain rights to protect citizens from irrevocable acts counters the individual liberty argument. p. 556

Which task is most likely to give terminally ill patients a sense of completion in relationships with family and friends? Recognition of a transcendent realm Transmission of knowledge and wisdom Transfer of fiscal, legal, and formal social responsibilities Expression of regret, forgiveness, and gratitude to family and friends

Expression of regret, forgiveness, and gratitude to family and friends Expression of regret, forgiveness, and gratitude to family and friends is most likely to give terminally ill patients a sense of completion in relationships with family and friends. Recognition of a transcendent realm is most likely to give terminally ill patients a sense of meaning about life in general. Transmission of knowledge and wisdom is most likely to give terminally ill patients a sense of meaning about one's individual life. The transfer of fiscal, legal, and formal social responsibilities is most likely to give terminally ill patients a sense of completion with worldly affairs.

What is the basic principle that is associated with hospice care? Family centered care Focus is on care not cure Treating client suffering Promoting client autonomy

Focus is on care not cure Hospice is a multidisciplinary team approach that focuses on patient care, not cures. Palliative care is patient and family-centered care that optimizes quality of life anticipating, preventing, and treating suffering. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs. Palliative caregivers promote patient autonomy, access to information, and choice. Hospice care incorporates many of the principles of palliative care. DIF: Cognitive Level: Apply (Application)REF: page 5TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Following the death of a loved one, what term describes a person's reaction to the loss? Grief Mourning Depression Bereavement

Grief Following the death of a loved one, a person's reaction to the loss is grief. Mourning refers to things people do to cope with grief, including shared social expressions of grief such as viewing hours, funerals, and bereavement groups. A diagnosis of clinical depression should be carefully distinguished from characteristics of the normal grieving process. Bereavement, derived from the Old English word berafian meaning, "to rob," is the period of grieving after a death.

According to the dual process model of coping, following the death of a loved one, which processes are loss oriented? Select all that apply. Grief work Breaking bonds Distracting from grief Attending to life changes Avoiding restoration changes

Grief work Breaking bonds Avoiding restoration changes According to the dual process model of coping, loss-oriented processes include grief work, breaking bonds, and avoiding restoration changes. Distracting from grief and attending to life changes are restoration-oriented processes.

Which concept introduced by Freud describes the process of looking at the past, reliving memories, and detaching from the deceased? Coping Grief work Passive grief Active mourning

Grief work Freud introduced the concept of "grief work," the process of looking at the past, reliving memories, and detaching from the deceased. Strobe suggests a dual process model of coping. Passive grief and active mourning are aspects of Worden's task-based model of grief.

At which sites may hospice care be provided? Select all that apply. Homes Hospitals Nursing homes Doctors' offices Treatment centers Freestanding hospice centers

Homes Hospitals Nursing homes Freestanding hospice centers Hospice care may be provided in homes, hospitals, nursing homes, or freestanding hospice centers. Generally, doctors' offices and treatment centers are not sites of hospice care, as the patient must choose hospice care rather than curative treatments.

Which is a model of care that supports and cares for patients facing death regardless of age, diagnosis, or the ability to pay? Hospice Medicare Kübler-Ross Dual process

Hospice Hospice is a model of care that supports and cares for patients facing death regardless of age, diagnosis, or the ability to pay. Medicare is the federal government's national program that provides health insurance for older adults. The Kübler-Ross model describes the phases of responding to a terminal illness. Dual process is a model of coping and bereavement.

Which assessment findings are associated with approaching death? Select all that apply. Increased drowsiness Increased blood pressure Progressive weakness Decreased heart rate Loss of appetite

Increased drowsiness Progressive weakness Loss of appetite The process of dying varies based upon the underlying cause. Some general signs of approaching death include growing weakness, loss of appetite, and increased drowsiness, an increase in heart rate, and a decrease in blood pressure. REF: 558-559

According to the U.S. Patient Self -Determination Act (PSDA), who may decide whether or not refuse life-sustaining or life-prolonging treatments? Select all that apply. Nurses Doctors Institutions Individual patients Designated patient surrogates

Individual patients Designated patient surrogates According the PSDA, an individual patient or designated surrogate can decide whether or not to refuse life-sustaining or life-prolonging treatments. Nurses, doctors, and institutions may play a role in educating patients and surrogates to make informed decisions in these cases, but they will not make the final decision.

What purpose does the grieving process serve when someone has experienced the death of a loved one? It outlines the required steps to managing the deceased's affairs. It enables people to accept and reconcile with the loss and adapt to change. It provides simple, sequential, linear steps to follow after losing a loved one. It allows for a long period of time for feeling pervasive guilt and unhappiness.

It enables people to accept and reconcile with the loss and adapt to change. Loss is part of the human experience, and grieving is the response that enables people to accept and reconcile with the loss and adapt to change. The grieving process does not outline steps to managing the deceased's affairs. The grieving process is complex and non-sequential. Pervasive guilt and unhappiness for a long period of time may indicate the person has symptoms of major depressive disorder.

Which are essential nursing skills for practicing the art of presence for terminally ill patients? Select all that apply. Talking Turning Bathing Listening Observing

Listening Observing To use the art of presence, two essential skills are listening and observing. Talking is not considered an essential skill of practicing the art of presence and my interfere in some circumstances. Turning and bathing may be useful in helping terminally ill patients feel more physically comfortable but are not considered aspects of the art of presence.

The argument that providing patients with relief from suffering through physician-assisted suicide is a display of beneficence would not hold up under what condition? Legal bans Misdiagnosis of the illness Disagreement among family members Government intervention to protect citizens

Misdiagnosis of the illness Beneficence means to do good, and doing good means to preserve and support life. Patients could benefit from relief that is now legally available to people who have physicians who are willing to risk assisting them to die. On the other hand, a misdiagnosis of the illness, inadequate assessment of competence, or pressure from the family or physician might place the patient in jeopardy. The argument that providing patients with relief from suffering through physician-assisted suicide is a display of beneficence could still be put forth in the context of legal bans, disagreement among family members, and government intervention to protect citizens. Pg 556

Medicare is the federal government's national program that provides health insurance for older adults. What is the most accurate description of how this fee-for-service system works? Individuals choose among competing insurers for their care. All individuals are required by law to obtain health insurance coverage. More medical services result in more reimbursement for healthcare providers. Basic services are provided, but those who can afford to pay more receive faster access to better-quality services.

More medical services result in more reimbursement for healthcare providers. Medicare is a fee-for-service system, which means that more medical services result in more reimbursement for healthcare providers. In a multipayer system, individuals choose among competing insurers for their care. An individual mandate requires all individuals to obtain health insurance coverage. In a two-tiered system, basic services are provided by the government, but those who can afford to pay more receive faster access to better-quality services

Following the death of a loved one, what term describes the things people do to cope, including the funeral and bereavement groups? Grief Mourning Depression Bereavement

Mourning Mourning refers to things people do to cope with grief including shared social expressions of grief such as viewing hours, funerals, and bereavement groups. Following the death of a loved one, a person's reaction to the loss is grief. A diagnosis of clinical depression should be carefully distinguished from characteristics of the normal grieving process. Bereavement, derived from the Old English word berafian meaning, "to rob," is the period of grieving after a death.

When caring for a terminally ill patient being treated with an opioid drug for pain, what should guide how much drug the nurse administers? Only the manufacturer's recommended dosage Not so much to cause dependency in the patient As much as objective measures of pain indicate is necessary No more and no less than what is required to relieve symptoms

No more and no less than what is required to relieve symptoms When caring for a terminally ill patient being treated with an opioid drug for pain, the nurse should administer the drug in an amount no more and no less than what is required to relieve symptoms. The nurse's administration of the drug should not be guided by only the manufacturer's recommended dosage or not so much to cause dependency in the patient. The only measure of pain is the patient's subjective reporting of it.

Which ethical concept regarding client care poses the greatest concern for a nurse providing end-of-life care for a client considering euthanasia? Nonmaleficence Beneficence Autonomy Individual liberty

Nonmaleficence An ethical concept relevant to euthanasia is that of nonmaleficence, or doing no harm and considering whether helping to end life is an act of harm. None of the other ethical concepts is as directly related to the actions of nursing at the end of a client's life. REF: 556

At what point in the end-of-life process does anticipatory grief occur? Immediately following the death of a loved one When curative efforts for a serious illness begins Once a life-threatening diagnosis has been received For several months following the death of a loved one

Once a life-threatening diagnosis has been received Once a life-threatening diagnosis has been received or curative efforts are stopped, individuals begin a period of grieving called anticipatory grief or anticipatory mourning. This type of grief is anticipatory in the sense that a future loss is being mourned in advance. Anticipatory grief typically does not occur when curative efforts for a serious illness begins, as patients and family members may have hope for recovery at this point. The grief that occurs immediately and for several months following the death of a loved one is not considered anticipatory.

Which kind of care optimizes quality of life anticipation, preventing, and treating suffering while addressing physical, intellectual, emotional, social, and spiritual needs?? Hospice Palliative Medicare Dual process

Palliative Palliative care optimizes quality of life anticipating, preventing, and treating suffering while addressing physical, intellectual, emotional, social, and spiritual needs. Hospice care supports patients facing death regardless of age, diagnosis, or ability to pay. Medicare is the federal government's national program that provides health insurance for older adults. Dual process is a model of coping and bereavement.

Which types of euthanasia exist? Select all that apply. Active Passive Assisted Voluntary Involuntary

Passive Voluntary Involuntary Three types of euthanasia exist. Passive euthanasia may be used when individuals are unable to consent. Voluntary euthanasia is typically performed when a person suffering from a terminal illness and in great pain chooses to end his or her life, often with the help of a physician. Involuntary euthanasia is actively ending a person's life, typically by the injection of a lethal drug. This active form of euthanasia is used in cases of the death penalty. Active and assisted are not considered types of euthanasia.

The nurse is caring for a patient who lost a child 2 years ago. Since then, the patient has not been able to keep a job and reports having thoughts of suicide. What proposed medical diagnosis may be appropriate? Complex grief Disenfranchised grief Major depression disorder Persistent complex bereavement disorder

Persistent complex bereavement disorder A medical diagnosis of persistent complex bereavement disorder applies to individuals whose bereavement persists beyond 12 months in adults and 6 months in children. Interference with normal functioning is the hallmark symptom that distinguishes typical grieving from a psychiatric disorder. Suicidal ideation and disinterest in living make this bereavement disorder particularly dangerous. Complex grief and disenfranchised grief are not medical diagnoses. Major depressive disorder is typically distinguished from those experiencing grief. pp. 561-562

Which document allows an individual to appoint another person to make health care-related decisions for them if they become unable to do so for themself? Advance directive Living will Do not resuscitate request Power of attorney for health care

Power of attorney for health care A medical or healthcare power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care if you are unable to do so. An advance directive may include a living will, that may include the request not to resuscitate, and/or a power of attorney for health care. REF: 557

Which are appropriate actions for the nurse providing end-of-life care for patients with dementia? Select all that apply. Proactively manage issues such as pain and depression. Eliminate medications that may detract from safety or quality of life. Catheterize the patient who is unable to communicate his or her need to urinate. Address irritable and uncooperative behaviors with medication to sedate the patient. Identify the patient's goals for care, and educate the family to minimize aggressive medical interventions.

Proactively manage issues such as pain and depression. Eliminate medications that may detract from safety or quality of life. Identify the patient's goals for care, and educate the family to minimize aggressive medical interventions. The nurse providing end-of-life care for patients with dementia should proactively manage issues such as pain and depression; eliminate medications that may detract from safety or quality of life; and identify the patient's goals for care, educating the family to minimize aggressive medical interventions. The patient who is unable to communicate his or her need to urinate is unlikely to require catheterization; the nurse should anticipate this need and provide assistance accordingly. Difficult behaviors, such as irritability or refusal to cooperate with care, are often forms of communication indicating discomfort in body, mind, or spirit. When caregivers use an anticipatory approach to care, they can frequently prevent or reduce behaviors that result when a person with dementia is unable to communicate important unmet needs.

What is the physician's role in physician-assisted suicide? Convincing the patient to end his or her life Administering medication to end the patient's life Providing the patient with the means to end his or her own life Advocating for the patient's legal right to end his or her own life

Providing the patient with the means to end his or her own life In physician-assisted suicide, the physician provides the patient with the means to end his or her own life, often in the form of medication and administration instructions. The physician may educate or counsel the patient about his or prognosis but should not attempt to convince the patient to end his or her life. Unlike euthanasia, in physician-assisted suicide, the physician makes the means of death available but does not act as the direct agent of death, such as by administering medication to end the patient's life. The physician may choose to advocate for patients' legal rights to end their own lives, but this is not the physician's role in physician-assisted suicide itself.

Which task is most likely to give terminally ill patients a sense of meaning about life in general? Recognition of a transcendent realm Transmission of knowledge and wisdom Transfer of fiscal, legal, and formal social responsibilities Expression of regret, forgiveness, and gratitude to family and friends

Recognition of a transcendent realm Recognition of a transcendent realm is most likely to give terminally ill patients a sense of meaning about life in general. Transmission of knowledge and wisdom is most likely to give terminally ill patients a sense of meaning about one's individual life. The transfer of fiscal, legal, and formal social responsibilities is most likely to give terminally ill patients a sense of completion with worldly affairs. Expression of regret, forgiveness, and gratitude to family and friends is most likely to give terminally ill patients a sense of completion in relationships with family and friends.

In a persistent vegetative state, what part of the brain remains functional, making wakefulness possible? Cortex Hypothalamus Medullary brainstem Reticular activating system

Reticular activating system In a persistent vegetative state, the reticular activating system remains functional, making wakefulness possible. The cortex is severely damaged, eliminating cognitive function. The hypothalamus and medullary brainstem remain intact to support cardiorespiratory and autonomic functions.

What nursing diagnosis is defined by vulnerability to a disorder following the death of a loved one caused by grief that does not follow normative expectations and manifests in functional impairment that may compromise health? Spiritual distress Impaired social interaction Risk for complicated grieving Risk for self-directed violence

Risk for complicated grieving Risk for complicated grieving is defined by vulnerability to a disorder following the death of a loved one caused by grief that does not follow normative expectations and manifests in functional impairment that may compromise health. Spiritual distress, impaired social interaction, and risk for self-directed violence may also be present but are not specific to the bereavement period.

The nurse caring for a terminally ill patient asks, "Are you worried about anything?" The patient does not immediately respond and turns away from the nurse to look out the window. What is the nurse's best response? Say, "It's alright, you don't have to tell me." Say, "Please tell me what you're thinking." Say nothing, and leave the room to let the patient be alone. Say nothing, and sit with the patient, allowing time for the patient to think.

Say nothing, and sit with the patient, allowing time for the patient to think. After asking an open-ended question, the nurse should say nothing and sit with the patient while allowing plenty of time for the patient to think. In practicing the art of presence, often saying little or nothing is a good approach. The nurse should not jump in with comments such as "It's alright, you don't have to tell me" or "Please tell me what you're thinking." Saying nothing and leaving the room is the not the best response, as the patient may appreciate the nurse's presence even if the patient doesn't wish to immediately respond to what the nurse has asked.p. 557

Following the death of a loved one, what symptoms may indicate major depressive disorder rather than grief? Select all that apply. Insomnia Self-loathing Continual guilt Thoughts of death Pervasive unhappiness

Self-loathing Continual guilt Pervasive unhappiness Following the death of a loved one, self-loathing, continual guilt, and pervasive unhappiness may indicate major depressive disorder rather than grief. Insomnia and thoughts of death may occur as a normal part of grief. p. 561

What technology can help people make sense of death and maintain a relationship with the deceased? Bluetooth Streaming Social media Personal blogs

Social media Social media can help people make sense of death and maintain a relationship with the deceased. In one study, Facebook profiles of deceased individuals were reviewed for the posts made by loved ones. Results indicate a potential for loved ones to continue a bond with the deceased by sharing memories, expressing sorrow, and gaining social support. Bluetooth, streaming, and personal blogs do not promote this continued sense of connection.

Which factor will have the greatest impact on end-of-life nursing care in the coming decades? Technological advancements Decrease in federal funding for healthcare The aging of the Baby Boomers generation The decline in those entering the nursing profession

The aging of the Baby Boomers generation In 2014, the U.S. Census Bureau released a report projecting that the number of Americans over the age of 65 is expected to almost double from 43.1 million in 2012 to 83.7 million by 2050. Every day for the next 19 years, 10,000 baby boomers will be turning 65. This burgeoning sector of the population will place unprecedented strains on a health care system where health spending is growing faster than the overall economy. As this population experiences terminal illness, the need for end-of-life care will increase as well. While the other options are factors, the greatest impact will come from the existence of unprecedented numbers of terminal ill and dying clients. REF: 554-555

Which argument for physician-assisted suicide represents a counterargument to the concept of individual liberty? Patients have the right to refuse or withdraw treatment. Assisted suicide enhances the opportunity for excellent end-of-life care for all patients. Every competent person has the right to make momentous decisions based on personal convictions. The government has the constitutional power to override certain rights to protect citizens from irrevocable acts.

The government has the constitutional power to override certain rights to protect citizens from irrevocable acts. The statement that the government has the constitutional power to override certain rights to protect citizens from irrevocable acts counters the individual liberty argument. The individual liberty argument for assisted suicide is represented by the statement that patients have the right to refuse or withdraw treatment. The quality of care argument for assisted suicide is represented by the statement that assisted suicide enhances the opportunity for excellent end-of-life care for all patients. The autonomy argument for assisted suicide is represented by the statement that every competent person has the right to make momentous decisions based on personal convictions. p. 556

A terminally ill client expresses to the nurse the desire to discuss end-of-life issues. What is likely to be the greatest barrier to that discussion? The health provider's hesitancy to prescribe palliative care The client's lack of knowledge regarding the various issues The family's unwillingness to acknowledge the inevitable The nurse's reluctance to discuss death-related issues

The nurse's reluctance to discuss death-related issues Despite being trained to nonjudgmentally discuss difficult and sensitive issues with patients and families, nurses are often afraid to talk about death. Talking about death is difficult because of the emotions that are involved. While the other options may be factors, the nurse's attitude and willingness to engage in such a conversation initially have the greatest impact. REF: 557

A dying client's family is concerned that the opioid pain medication being prescribed will hasten the client's death. Why? The Rule of Double Effect (RDE) prevents the use of opioids to facilitate a client's death. There is little research evidence to support that appropriate opioid management will result in an earlier death. Pain management for the terminally ill is the primary concern of the health care team. Addition to the opioid is a greater risk than is the possibility of a premature death.

There is little research evidence to support that appropriate opioid management will result in an earlier death. Pain is sometimes undertreated because the patient and/or family is concerned about sedation, addiction, and/or hastening the demise of their loved one. The RDE is a bioethical principle that allows a physician or APRN to make a decision, such as prescribing adequate pain medication, even though the pain medication might cause the patient to die sooner. There is little evidence, however, to support the concern that appropriate use of opioids will hasten death. DIF: Cognitive Level: Apply (Application)REF: page 13TOP: Nursing Process: PlanningMSC:NCLEX: Safe and Effective Care Environment

Which task is most likely to give terminally ill patients a sense of completion with worldly affairs? Recognition of a transcendent realm Transmission of knowledge and wisdom Transfer of fiscal, legal, and formal social responsibilities Expression of regret, forgiveness, and gratitude to family and friends

Transfer of fiscal, legal, and formal social responsibilities The transfer of fiscal, legal, and formal social responsibilities is most likely to give terminally ill patients a sense of completion with worldly affairs. Recognition of a transcendent realm is most likely to give terminally ill patients a sense of meaning about life in general. Transmission of knowledge and wisdom is most likely to give terminally ill patients a sense of meaning about one's individual life. Expression of regret, forgiveness, and gratitude to family and friends is most likely to give terminally ill patients a sense of completion in relationships with family and friends.

Which task is most likely to give terminally ill patients a sense of meaning about one's individual life? Recognition of a transcendent realm Transmission of knowledge and wisdom Transfer of fiscal, legal, and formal social responsibilities Expression of regret, forgiveness, and gratitude to family and friends

Transmission of knowledge and wisdom Transmission of knowledge and wisdom is most likely to give terminally ill patients a sense of meaning about one's individual life. Recognition of a transcendent realm is most likely to give terminally ill patients a sense of meaning about life in general. The transfer of fiscal, legal, and formal social responsibilities is most likely to give terminally ill patients a sense of completion with worldly affairs. Expression of regret, forgiveness, and gratitude to family and friends is most likely to give terminally ill patients a sense of completion in relationships with family and friends.

Which factor will have the most positive impact when the nurse asks patients or families to make difficult decisions at the end of life? Clear advance directive Durable power of attorney Excellent symptom management Well-established therapeutic relationship

Well-established therapeutic relationship A well-established therapeutic relationship will have the most positive impact when the nurse asks patients or families to make difficult decisions at the end of life. A clear advance directive and durable power of attorney are helpful in clarifying end-of-life care management but will not best facilitate positive communication between the nurse and patient or family. Excellent symptom management is a hallmark of palliative nursing but also will not have the most positive impact on discussions involving end-of-life care.

The time of death used on the death certificate is identified at what point? When the medical examiner releases the patient. When the funeral home arrives to move the patients body. When the nurse observes the patient has been without a heartbeat or breath for two minutes. When the family member or other person present identifies the patient has stopped breathing.

When the nurse observes the patient has been without a heartbeat or breath for two minutes. The time of death on the death certificate is identified when the nurse observes the patient has been without a heartbeat or breath for 2 minutes. The time of death is not identified when when the medical examiner releases the patient, when the funeral home arrives to move the patient's body, or when the family member or other person present identifies the patient has stopped breathing.

Which reflexes may remain in patients with brain death? Select all that apply. Cough Pupillary Withdrawal Deep tendon Plantar flexion

Withdrawal Deep tendon Plantar flexion In patients with brain death, spinal reflexes, including withdrawal, deep tendon, and plantar flexion may remain. Brainstem reflexes, including cough and pupillary reflexes, are lost. p. 555