Unit 8: Grief and Death/Dying
A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating? a.Peacefulness b.Decreased socialization c.Decreased decision making d.Anxiety about unfinished business
Answer: B
The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, the nurse would do which first? a.Auscultate for breath sounds. b.Administer PRN pain medication. c.Check pressure points for skin breakdown. d.Ask family about patient's food and fluid intake.
Answer: B
While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife? a.A priest b.Dying wife c.Hospice staff d.Husband of dying wife
Answer: B
Grieving with a 4-7 year old: What is the understanding and response to death?
Concept of Death Death still seen as reversible Feeling of responsibility (or guilt!) because of wishes and thoughts Grief Response More verbalization Great concern with process. How? Why? May act as though nothing has happened General distress and confusion
Grieving with a 7-11 year old: What is the understanding and response to death?
Concept of Death Still wanting to see death as reversible but beginning to see it as final Death seen as punishment Grief Response Specific questions Desire for complete detail What is the right way to respond? Starting to have ability to mourn and understand mourning
Cultural beliefs regarding end of life care: Judaism
Judaism Prolongation of life is important (a client on life support must remain so until death) A dying person should not be left alone (a rabbi's presence is desired; belief that the spirit should not be alone when it leaves the body at the time of death, so a constant vigil is kept in the room of the dying patient. They also believe that all body tissues must be buried with the individual.
Grieving with a 4-7 year old: What are their immediate needs?
Needs of the 4-7 year old: Clear answers in simple terms to the questions that they ask, no matter how improbable their fears seem An accepting listener to the memories s/he has of the deceased Explanations to refute the magical beliefs that feed their fears Acceptance of play, artwork, songs, etc. about the events surrounding the death
Grieving with a 7-11 year old: What are their immediate needs?
Needs of the 7-11 year old: To be taken seriously, no matter how shallow his/her concerns seem To be included in family discussions about the changes brought about by the death To have his/her ways of grieving accepted While this age-group may understand death intellectually, they may have great difficulty understanding it emotionally.
Nursing assessment for end of life care (5)
(Varies with the patient's condition) Brief review of body systems Assess for discomfort, pain, nausea, and dyspnea Evaluate and manage co-morbidities Assess patient and family's ability to cope with the terminal diagnosis and its consequences Abbreviated physical assessment (focus on changes that accompany terminal illness and disease process)
Kubler-Ross stages of grief:
1. denial 2. anger 3. bargaining 4. depression 5. acceptance
Palliative care:
focuses on reducing symptom severity for long term illness and improve quality of life (particularly end stage, or people who have illnesses that are not very responsive to treatment)
Grieving with a 11-18 year old: What is the understanding and response to death?
Concept of Death Ability to abstract Beginning to conceptualize death Grief Response Extreme sadness Denial Regression More often willing to talk to people outside of family and peer support Risk-taking
Cultural beliefs regarding end of life care: amish
Amish Funerals are conducted in the home without a eulogy, flower decorations or any other display; caskets are plain and simple, no adornment At death, a woman is usually buried in her bridal dress One is believed to live on after death, either with eternal reward in heaven or punishment in hell
A 74-year-old female admitted for pneumonia tells the nurse that she does not want health care professionals to attempt CPR. What is important for the nurse to verify in the medical record related to the patient's directive? A. The physician has written and signed the DNR order. B. The living will is signed by the patient and two witnesses. C. The patient's durable power of attorney agrees with the decision. D. There is an advance directive related to artificial nutrition and hydration.
Answer: A CPR will be performed for respiratory or cardiac arrest unless a DNR (do not resuscitate) order is written and signed by the physician in the patient's medical record. The DNR order documents the patient's desire to avoid CPR.
A patient with terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." What is the most appropriate response by the nurse? A. "What are your feelings about being so sick and thinking you may die soon?" B. "None of us know when we are going to die. Is this a particularly difficult day?" C. "Would you like for me to call your spiritual advisor so you can talk about your feelings?" D. "Perhaps you are depressed about your illness. I will speak to the doctor about getting some medications for you."
Answer: A The most appropriate response to psychosocial questions is to acknowledge the patient's feelings and explore his or her concerns. This option does both and is a helpful response that encourages further communication between the patient and nurse.
A 39-year-old woman near death from metastatic cancer becomes restless and confused. What interventions would be the most appropriate for the nursing management of these symptoms? A. Avoid administering pain medication until the patient is calm and alert. B. Stay physically close to the patient and use a soothing voice and soft touch. C. Turn on the television to provide a distraction, and contact the hospital chaplain. D. Restrain the patient to prevent injury, and ask family and visitors to leave the room.
Answer: B Appropriate interventions for restlessness and confusion when a patient is near death include the following: use soft touch and voice, stay physically close to the patient, and remain calm. Use soothing music instead of the radio or television. Make referrals (e.g., hospital chaplain, spiritual leader) based on patient's spiritual and cultural preferences. Family visitors may provide comfort. Uncontrolled pain may be the cause of restlessness and confusion. Withholding pain medication or restraining the patient would be inappropriate and may cause more restlessness
The nurse is providing anticipatory guidance to the family of a patient who is expected to die within the next 12 to 24 hours. What physical manifestations of approaching death will the nurse discuss with the family? A. The patient will be incontinent of urine after frequent seizures. B. The skin will feel cold and clammy, with mottling on the extremities. C. The patient will have increased pain, and the sense of touch will be enhanced. D. The gag reflex is exaggerated, and the patient will exhibit deep, rapid respirations.
Answer: B As death approaches, the following physical manifestations occur: cold, clammy skin; mottling on hands, feet, arms, and legs; jerking (not seizures) occurs in patients on large amounts of opioids; bowel and bladder incontinence; decreased perception of pain and touch; loss of gag reflex; and Cheyne-Stokes respirations.
The dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will best meet this patient's needs? A. Encourage more physical activity. B. Assess for pain, constipation, and urinary retention. C. Assess for spiritual distress and restrain in varying positions. D. Assess for quality, intensity, location, and contributing factors of discomfort.
Answer: B Assessing for all reversible causes of delirium (i.e., pain, constipation, urinary retention, dyspnea, sensory hyperstimulation) so they can be reversed may help decrease confusion and restlessness. Encouraging more physical activity may prevent further skin breakdown, but it will be difficult as weakness and fatigue are expected at the end of life. Keeping the skin clean and dry and preventing shearing forces will better avoid further skin breakdown. Spiritual distress may be a cause of restlessness, but the patient should not be restrained.
The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of ___________. A. 3 months or less to live B. 6 months or less to live C. 12 months or less to live D. 18 months or less to live
Answer: B There are two criteria to be eligible for hospice care. The first is that the patient wishes to receive hospice, not curative care, and the second is that the physician certifies that the patient has a prognosis of 6 months or less to live.
When the nurse assesses the patient, what manifestation indicates to the nurse that the patient is very near death? A. The patient responds to noises. B. The patient's skin is mottled and waxlike. C. The heart rate and blood pressure increase. D. The patient is reviewing his life with his family.
Answer: B When a patient is very near death, the skin will be waxlike, cold, clammy, and mottled or cyanotic. Although hearing is the last sense patients lose before death, it is unlikely that they will be responding to noises when very near death. Initially the heart rate increases, but later slows and the blood pressure decreases. Near death, speaking may be slow and unusual and indicate confusion.
A nurse has been working full time with terminally ill patients for 3 years. He has been experiencing irritability and mixed emotions when expressing sadness since four of his patients died on the same day. To optimize the quality of his nursing care, he should examine his own: a.full-time work schedule. b.past feelings toward death. c.patterns for dealing with grief. d.demands for involvement in patient care.
Answer: C
The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. Who is responsible for making the decision about EOL measures when the patient cannot communicate his or her specific wishes? a.Notary and attorney b.Physician and family c.Wife and adult children d.Physician and nursing staff
Answer: C
When going to the hospital, which forms should patients be taught to bring with them in case end-of-life care becomes an ethical or legal issue? . Euthanasia B. Organ donor card C. Advance directives D. Do not resuscitate (DNR)
Answer: C Advance directives are written documents that provide information about the patient's wishes for medical care and treatments and his or her designated spokesperson. Euthanasia is not a form; it is a deliberate act of hastening death. Organ donor cards only state that the patient wants to donate organs or their body for transplants or for scientific research. Do not resuscitate (DNR) or comfort measures only is a written order from the physician that documents a patient's wishes to avoid CPR.
A man died at the age of 71 following a myocardial infarction that he experienced while performing yard work. What would indicate that his wife is experiencing prolonged grief disorder? A. Initially she denied that he died. B. Talking about her husband extensively in year following his death. C. Stating that she expects him home soon on the anniversary of his death. D. Crying uncontrollably and unpredictably in the weeks following her husband's death.
Answer: C Denial of an individual's death that persists beyond 6 months is indicative of prolonged grief disorder. Strong emotions or denial immediately following the death are considered to be expected responses, and talking about the deceased loved one is not considered to be evidence of the disorder.
How should the nurse provide appropriate cultural and spiritual care for the patient and family to best be able to help them when nearing the end of the patient's life? A. Assess the individual patient's wishes. B. Call a pastor or priest for the family to help them cope. C. Assess the beliefs and preferences of the patient and family. D. Do not insult African Americans by suggesting hospice care.
Answer: C Differences among spiritual and culture beliefs and values related to death and dying are innumerable. The individual patient and family must be assessed to avoid stereotyping individuals with different spiritual and cultural belief systems.
During admission of a patient diagnosed with metastatic lung cancer, what should the nurse assess for as a key indicator of clinical depression related to terminal illness? A. Frustration with pain B. Anorexia and nausea C. Feelings of hopelessness D. Inability to carry out activities of daily living
Answer: C Feelings of hopelessness are likely to be present in a patient with a terminal illness who has clinical depression. This can be attributed to lack of control over the disease process or outcome. The nurse should routinely assess for depression when working with patients with a terminal illness.
After an 18-year-old patient died of severe injuries from a motor vehicle crash, the nurse who provided care is feeling helpless and powerless. What intervention would be most appropriate to help this nurse deal with these emotions and the death of this patient? A. Maintain daily contact with the adolescent's family for the next 2 to 3 months. B. Request a prescription for an anxiolytic to aid in dealing with the death of this patient. C. Attend a debriefing session with health team members to allow expression of feelings. D. Avoid caring for any other patients who are terminally ill until the feelings of grief subside.
Answer: C The nurse needs to express feelings of loss and grief. Interventions such as a peer support, professionally assisted groups, or informal discussion sessions are appropriate ways for the nurse to express feelings related to death and dying.
For the past 5 years Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? A. Adaptive grief B. Disruptive grief C. Anticipatory grief D. Prolonged grief disorder
Answer: D
The primary purpose of hospice is to: A.allow patients to die at home. B.provide better quality of care than the family can. C.coordinate care for dying patients and their families. D.provide comfort and support for dying patients and their families.
Answer: D
The nurse is evaluating whether a hospice referral is appropriate for a 69-year-old man with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program? A. The hospice medical director certifies admission to the program. B. The physician guarantees the patient has less than 6 months to live. C. The patient has completed both advance directives and a living will. D. The patient wants hospice care and agrees to terminate curative care.
Answer: D There are two criteria for admission to a hospice program. The first criterion is the patient must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness. The second criterion is that the patient must be considered eligible for hospice. Two physicians must certify that the patient's prognosis is terminal with less than 6 months to live.
A patient has been receiving palliative care for the past several weeks in light of her worsening condition following a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." What should the nurse recognize that the patient is experiencing? A. Apnea B. Bradypnea C. Death rattle D. Cheyne-Stokes respirations
Answer: D Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is usually seen as a person nears death.
The children caregivers of an elderly patient whose death is imminent have not left the bedside for the past 36 hours. In the nurse's assessment of the family, what findings indicate the potential for an abnormal grief reaction to occur (select all that apply)? a.Family cannot express their feelings to one another. b.Dying patient is becoming more restless and agitated. c.A family member is going through a difficult divorce. d.Family talks with and reassures the patient at frequent intervals. e.Siblings who were estranged from each other have now reunited.
Answers: A, C
An 80-year-old female patient is receiving palliative care for heart failure. Primary purpose(s) of her receiving palliative care is (are) to (select all that apply) A.improve her quality of life. B.assess her coping ability with disease. C.have time to teach patient and family about disease. D.focus on reducing the severity of disease symptoms. E. provide care that the family is unwilling or unable to give.
Answers: A, D,
Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient? (Select all that apply.) A. Strong spiritual beliefs B. Medical diagnosis of the patient C. Advanced age of the patient D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death
Answers: A, D, E Acceptance of an impending loss, spiritual beliefs, and adequate preparation time are all associated with positive outcomes regarding anticipatory grief. The age and diagnosis of the patient are not key factors in influencing the quality of the anticipatory grief of the caregiver.
Grieving with a 2-4 year old: What is the understanding and response to death?
Concept of Death Death seen as reversible Grief Response Intensive response but brief Very present oriented Most aware of changes in patterns of care Asking questions repeatedly
Cultural beliefs regarding end of life care: Buddhism
Buddhism A shrine to Buddha may be placed in the client's room Time for meditation at the shrine is important and should be respected Clients may refuse medications that alter their awareness (e.g. opioids) After death, a monk may recite prayers for 1 hour (need not be done in the presence of the body)
Cultural beliefs regarding end of life care: catholic/orthodox
Catholic and Orthodox Priest anoints the sick Other sacraments before death include reconciliation and holy communion
respiratory changes at the end of life (2)
Death rattle (respirations may be rapid or slow, shallow, irregular; breath sounds wet and noisy, both audibly and on auscultation—caused by mucus trapped in the airways) Cheyne-Stokes respirations (pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing)
Cultural beliefs regarding end of life care: islam
Islam Second-degree male relatives such as cousins or uncles should be the contact people and determine whether the client or family should be given information about the client The client may choose to face Mecca (west or southwest in the US) The head should be elevated above the body, discussions about death usually are not welcomed; stopping medical treatment is against the will of Allah Grief may be expressed through slapping or hitting the body
Current legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected. How is it determined if this has happened?
EEG (determines if there is brainwave activity)
Cultural beliefs regarding end of life care: jehovah's witness
Jehovah's Witnesses Members are not allowed to receive a blood transfusion Members believe that the soul cannot live after the body has died
How do you do a nursing assessment when a patient is in their final hours of life?
Essential data only when patient is in final hours of life
During nursing implementation for end of life care, patients and families may have several common fears. list 4.
Fear of pain Fear of SOB Fear of lonliness and abandonment Fear of meaninglessness
grief vs. depression
Grief Experienced in waves Diminishes in intensity over time Healthy self-image Hopelessness Response to support Overt expression of anger Preoccupation with deceased Depression Moods and feelings are static Consistent sense of depletion Sense of worthlessness and disturbed self-image Pervasive hopelessness Unresponsive to support Anger not as pronounced Preoccupation with self
Cultural beliefs regarding end of life care: Hinduism
Hinduism Rituals include tying a thread around the neck or wrist of the dying person, sprinkling the person with special water, and placing a leaf of basil on their tongue After death, the sacred threads are not removed, and the body is not washed
list as many physical manifestations at the end of life as you can: (9)
Metabolism slowed Bradycardia Hypotension Decrease in urine output Loss of sphincter control Fecal incontinence before imminent death or at time of death Gradual loss of muscular movements Difficulty speaking, swallowing Mottling on hands, feet, arms, leg; cold, clammy skin
Cultural beliefs regarding end of life care: mormon
Mormons A sacrament may be administered if the client requests
Grieving with a 11-18 year old: What are their immediate needs?
Needs of the 11-18 year old: To be included in planning & decision making To be informed of what to expect in terms of events, ceremonies, rituals, etc. To know what to expect from various relatives To know what is expected of them To witness adults grieving so they can learn adult ways to grieve To be encouraged to talk about what they think and feel and have their thoughts and feelings respected
Grieving with a 2-4 year old: What are their immediate needs?
Needs of the 2-4 year old: Kind and understanding tone of voice and demeanor Encouragement to talk about how s/he feels in whatever way s/he can express it Permission to "play about" death and the events surrounding the experience Open and direct manner that says "I'm with you and you are with me. There are no secrets." Sharing of how you feel or felt when a similar thing happened Reassurance that remaining family members will take care of the child
DIFFERENCE BETWEEN PALLIATIVE AND HOSPICE:
Palliative: patients still receive treatments ex: dialysis, etc. treatments are given for comfort and maintain functionality, even if its low level functionality. Hospice: there is no more treatment given with the intent to combat illness, and the idea is meant to maintain patient comfort in preparation/expectation of death. (general time frame is 6 months. but this doesn't mean they will be kicked out of hospice. Hospice is generally a type of care not a floor or place of care.
Criteria for patients to begin Hospice care (2)
Patient must desire the services and agree in writing that only hospice care (not curative care) can be used to treat the terminal illness The patient must be considered eligible for hospice
Cultural beliefs regarding end of life care: protestant
Protestant No last rites are provided; prayers are given to offer comfort and support
Nursing Implementations for end of life care (7)
Psychosocial care Anxiety and depression Anger Hopelessness and powerlessness Fear Communication/empathy Legal and ethical issues
What criteria must a patient meet to be considered eligible for hospice?
Terminal prognosis < 6 months to live Medicare, Medicaid and insurers require a physician to certify the <6month prognosis (Not a "Guarantee" death to occur in < 6 months Many hospice patients will survive past the "6 month" mark)
conventional types of grief (3)
abbreviated (short grieving period) anticipatory (knowing someone is going to die and being able to prepare for the loss) adaptive (healthy response of someone who accepts reality of death)
Types of loss:
actual, perceived, anticipatory
true or false: medical insurances do NOT continue to reimburse for hospice services if the patient survives past the 6 month mark
false. (Medicare, Medicaid and insurers will continue to reimburse for hospice services even if the patient survives past the 6 month mark.)
true or false: if the patient at end of life says "they are not religious" then they will likely not have spiritual needs.
false. (all patients at end of life and families will have spiritual needs)
Who makes up the core team to provide care for palliative patients:
doctors, nurses, social workers, clergy/chaplains,
actual loss:
loss of a person, extremity, loss of independence or health
percieved loss:
loss of something that typically just has value to the person, such as divorce may hear "you are better off without them/it"
Spiritual distress: characteristics and why it may occur
may occur as patients with deep-seated spiritual beliefs begin to deal with their terminal illness and related issues. Characteristics of spiritual distress include anger toward God or a higher being, change in behavior or mood, desire for spiritual assistance or displaced anger toward clergy.
why is it recommended that patients with chronic disease with expected poor prognosis go into palliative care earlier rather than later?
patients and family member receive a lot more supportive care and benefits while in palliative care than regular medical care.
what is inhibited grief?
person suppresses their grief and doesn't progress through the grieving process
dysfunctional types of grief (2)
prolonged grief disorder inhibited grieving
prolonged grief disorder
prolonged grieving for over 2 years without any resolution or moving forward. (can be so severe, it inhibits persons from being functional)
anticipatory loss:
terminal illness, knowing that life will end soon and mourning loss of future (both patient and loved ones)
true or false: Patients can receive care for conditions that arise after starting hospice
true
True or false: registered nurses, often a nursing supervisor, can pronounce death prior to the appearance of a doctor.
true- depending on the facility and state
true or false: Patients can withdraw from hospice at any point.
true. (Patients can withdraw from hospice at any point if a new therapy or treatment is found, or if the patient or family decide they want to continue with possible curative therapies.)
How often are home hospice patients typically assessed?
typically weekly
when is it recommended that patients go into hospice care?
when patient prognosis is 6 months or less, and patient wants to "go when its time" with minimal intervention.