Chapter 08 - Concepts of Care for Patients at End of Life

The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit? A. Aggressive brain tumor and needs daily assistance with ambulation and bathing B. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea C. Inoperable lung cancer and considering whether to have radiation and chemotherapy D. Prostate cancer with bone metastases and has new-onset leg weakness and tingling

A. Assisting clients with activities of daily living such as ambulation and bathing is a common role for assistive personnel working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.) Select all that apply. A. The laboring mother expecting her first child B. A client with a non-life-threatening illness C. A person who currently has advance directives D. The comatose client who was injured in an automobile crash E. The client with end-stage kidney disease

A. B. C. E. All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so.The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.) Select all that apply. A. Do not encourage the client to stay awake. B. Offer to insert a Foley catheter for comfort. C. Place warm blankets on the client to keep them warm. D. Use moist swabs to keep the mouth and lips moist. E. Encourage the client to eat ice chips and drink as much as possible. F. Make sure the room is well-lit.

A. B. D. When caring for a client who is actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client's mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort.

The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet? A. Facilitating a peaceful death for the client B. Ensuring an expedited death C. Meeting all of the client's needs D. Avoiding symptoms of client distress

A. Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do? A. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. B. Teach the family to recognize signs of client discomfort such as restlessness or grimacing. C. Clarify family members' feelings about the meaning of client behaviors and symptoms. D. Develop a plan for care after assessing the needs and feelings of both the client and the family.

A. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first? A. Morphine sulfate sublingually as needed B. Albuterol solution per nebulizer D. Prednisone elixir 10 mg orally D. Oxygen 2 to 6 L/min per nasal cannula

A. Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol, oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate? A. Place the client in a side-lying position so secretions can drain. B. Use a Yankauer suction tip to remove secretions from the client's upper airway. C. Position the client in a high-Fowler position to minimize secretions. D. Assist the family in leaving the room so that they can compose themselves.

A. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removal of secretions, because it is not effective and may even agitate the client.

The daughter of a client who is dying states, "I don't want my father to be uncomfortable." How will the nurse respond? A. "Your father will be closely monitored and cared for." B. "Do you want to talk to the bereavement nurse?" C. "Your father will be sedated and comfortable." D. "We will send him to hospice when the time comes."

A. The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as providing support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question, it is a nontherapeutic response and may shut off the dialog. The client who is dying is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep the client alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort and it closes the dialog.

A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client? A. Ask the provider if the medications can be discontinued or substituted. B. Do not administer the medications and document: "Unable to swallow." C. Ask the pharmacy to substitute intramuscular (IM) equivalents for the medications. D. Crush the pills, open the sustained-release capsules, and mix them with a spoonful of applesauce.

A. The nurse will contact the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.) Select all that apply. A. A durable power of attorney for health care is the same as a durable power of attorney for one's health care. B. A living will identifies health care wishes regarding end of life treatment. C. A health care proxy can only make decisions once a person no longer has their own ability to make decisions. D. In order to make a health care decision, a person much be totally oriented. E. A living will contains funeral directives as well as last wishes for family. F. Advance directive are the same from state to state.

B. C. Advance directive vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as the durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, and nutrition or hydration as well as resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make a health care decisions, a person does not need to be totally oriented. However, he or she must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference.

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? A. Explains to the family that aspiration may be a concern. B. Administers nutrition and fluids through a nasogastric tube. C. Teaches the family how to provide oral care. D. Obtains a physician order to initiate an IV line.

C. Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? A. A 62 year old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg. B. A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. C. A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations. D. A 30 year old with AIDS-associated dementia and agitation who is asking for assistance with calling family members.

C. Management of pain is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

Which condition, when assessed in a client who is dying requires the nurse to take action? A. Alternating apnea and rapid breathing B. Cool extremities C. Moaning D. Anorexia

C. Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying.

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement? A. Administer intravenous hydration. B. Call the family to come in right away. C. Offer ice chips. D. Bring in the client's favorite food.

C. The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not currently necessary.

A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem nursing action is appropriate? A. Removing dentures and any prosthetics B. Raising the head of the bed and opens the client's eyes C. Asking the family if they wish to help wash the client D. Asking the family to leave during post-death care

C. The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

The family of a client who is unconscious and dying realizes that their mother will die soon. The client's children are having a difficult time letting go. How will the nurse respond to the needs of this family? A. "She will soon be in a better place." B. "She would not want you to cry; she needs you to be strong." C. "This must be difficult for you." D. "Things will be ok, just try to enjoy your time together."

C. The nurse responds by stating, "This must be difficult for you." This statement tells the family that the nurse is aware of their needs. The nurse knows that she must accept whatever the grieving person says about the situation, must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "She would not want you to cry" or "Things will be ok," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms because such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? A. "Do you believe in God?" B. "Where have you been attending church?" C. "Tell me about religion in your life." D. "What gives you purpose in life?"

D. The most accurate data about the client's spirituality would come from the question, "What gives you purpose in your life?" Spirituality arises from whatever or whoever provides the client ultimate purpose and meaning. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is considered by many people to be affiliation or membership in a faith community. Members of such a community may be supportive of the client if the client is a member, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on the defensive.

A client admitted to the hospital states, "Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?" How will the nurse respond? A. "You will need to see a lawyer to complete advance directives." B. "Advance directives are for those individuals who are critically ill." C. "You need to complete that paperwork before admission." D. "Advance directives allow a client to convey health care wishes."

D. The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care. This best addresses the client's comments. Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this.