Chapter 39, Hospice Care

A nurse notes that the patient on hospice has not had a bowel movement in 7 days. What should the nurse do first?

Assess the patient's abdomen. Before the nurse takes any action, the nurse should inspect, auscultate, and palpate the patient's abdomen to determine presence of peristalsis, firmness, tenderness, or distention. The nurse should plan treatment based on the assessment of the patient's abdomen.

After monitoring the vital signs of a patient in hospice, the nurse elevates the head of the bed. Which outcome does the nurse expect from this intervention?

Improved breathing patterns. Breathing patterns may become irregular in patients under hospice care and in patients approaching death. Elevation of the head of the bed relieves the patient from irregular breathing patterns. Elevating the head of the bed doesn't prevent the patient from falling. Neither a decrease in anxiety nor an increase in blood pressure is associated with this intervention.

The hospice nurse knows to plan care based on which philosophy?

Maximizing the quality of the patient's remaining life. Hospice care is focused on maximizing the quality and dignity of the patient's remaining life in the presence of terminal disease. Acute care is concerned with curing the patient. Rehabilitation care focuses on returning the patient to a previous level of functioning. Hastening the patient's death is illegal.

A nurse is caring for a patient in the beginning stages of the dying process. The patient has anorexia because of stomatitis. Which instruction would be most helpful to facilitate increased oral intake?

Provide high-protein liquid drinks The patient with stomatitis is likely not eating because his or her mouth is too painful to eat. Therefore, liquid protein drinks may be more tolerable. If the patient were not eating because of nausea and vomiting, it might be helpful to prepare only the patient's favorite foods, prepare the food outside the home, and make the dining process as enjoyable as possible.

A hospice patient has been prescribed metoclopramide (Reglan) for controlling nausea and vomiting and improving anorexia. Which instruction would be beneficial for the patient and family?

Take the medication 30 minutes before each meal and before bedtime. Reglan should be taken 30 minutes before each meal and before bedtime. It does not need to be taken with milk, and grapefruit juice need not be avoided.

A family member of a patient at the hospice center tells the nurse that the patient has been seeing and talking to people not visible to others. What does the nurse tell the family member?

The patient is having vision-like experiences. The patient who is nearing death often has vision-like experiences. Such patients often have visions of people or things that do not exist. The patient is not hallucinating, having a drug reaction, or preparing to "let go" from relationships.

A patient on hospice is unarousable and demonstrating the "death rattle," which is proving to be distressing for the patient's family. Which medication should the nurse request from the provider?

Transdermal scopolamine. Anticholinergic medications such as scopolamine can decrease secretions that cause the "death rattle." Albuterol and sublingual morphine can be used to decrease feelings of air hunger. Oral diphenhydramine would not be appropriate for this patient.

A nurse is reviewing the medication administration record of the patient on hospice for terminal cancer. The nurse notes the patient is administered droperidol (Inapsine) daily. The nurse knows this patient is likely experiencing which symptom?

Vomiting. Droperidol is used in the treatment of frequent vomiting. Anxiety is treated with medications such as lorazepam (Ativan). Constipation is treated with stool softeners or laxatives. Pain can be treated with various opioid and nonopioid analgesics.

The nurse cares for a patient in the terminal stage of leukemia who has opted for hospice care. When is the patient considered to be eligible for hospice care?

When two primary healthcare providers certify that the patient has less than 6 months to live. To be eligible for hospice care, two primary healthcare providers should certify that the patient is in the terminal stage and has less than 6 months to live. The certification should be from two primary healthcare providers, not just one. It is also important that primary healthcare providers do not guarantee the death of the patient within 9 months. Scope for further recovery is not a criterion for hospice care.

The hospice nurse knows that constipation is a problem in terminally ill patients. When opioids are initiated to treat pain, what intervention may be recommended to prevent constipation in the terminally ill patient?

Initiation of a stool softener and stimulant. Prevention of constipation is important; the initiation of a stool softener and stimulant will help counteract the side effect of an opioid. Often, terminally ill patients have nausea and vomiting, decreasing the ability to increase fluids or eat, which contributes to constipation. Terminally ill patients are generally weak and are unable to exercise, contributing to constipation.

The son of a patient on hospice tells the nurse he is concerned about his father's lack of oral intake. How should the nurse respond?

"As life comes to an end, the need for food and drink decreases. Your father will not starve to death." The nurse should educate the son that the patient will not starve to death or die of dehydration. Often, forcing the patient to eat or drink can cause more harm than good. Although offering the father's favorite foods may help to some degree, this is not the most helpful statement. Total parenteral nutrition is not often used for patients on hospice.

The family of a patient on hospice calls to tell the nurse that the patient is not breathing for 10 to 30 seconds at a time. What should the nurse tell the family first?

"Elevating the head of the patient's bed can provide relief for your loved one." The nurse should first tell the family how to make their loved one more comfortable, because this is the philosophy of hospice. Then the nurse should plan to visit the family. Also, the nurse should discuss the likelihood of impending death. Increasing the flow of the patient's oxygen may not be helpful to the patient.

A patient in hospice who is experiencing anxiety and fear reports nausea and vomiting. What would be the best instruction for this patient?

"Feel free to verbalize your fears." In some cases, severe anxiety and fear may cause nausea and vomiting. In such patients, it is important to encourage the patient to verbalize fears. This helps in reducing anxiety, which is the cause of vomiting in this case. Eating high-fiber foods is a general suggestion for patients with constipation and does not help reduce nausea and vomiting. Encouraging the patient to take medications as prescribed is a general nursing intervention. Avoiding strong-smelling foods is not relevant in the case of vomiting caused by anxiety and fear.

The family of an elderly patient who has been diagnosed with terminal cancer tells the nurse, "We can't afford hospice care. How are we going to provide for our mother?" What is the best way for the nurse to respond?

"If two physicians provide documentation that your mother has less than 6 months to live, Medicare will pay for hospice." Medicare and Medicaid will pay for hospice care if two physicians provide documentation that the patient has less than 6 months to live. Hospice is not a free service provided by churches. Medicaid does not require three physicians to attest to a patient's prognosis of less than 3 months to live. The nurse should not tell the family to sell the patient's home.

A nurse is caring for a patient receiving hospice through the Medicare Hospice Benefit. The patient is concerned about who will be there to comfort her family after she has passed. How should the nurse respond?

"The Medicare Hospice Benefit provides for bereavement counseling for 1 year after you have passed." The Medicare Hospice Benefit offers bereavement counseling for up to 1 year after the hospice patient has passed. The nurse should not make promises to the patient. Although the nurse should refer the family to support groups, this is not the most appropriate answer. The nurse should not tell the patient that her family will have only one another to rely on after she has passed.

A patient in the terminal stage of breast cancer is admitted to hospice. The family caregiver tells the nurse to reduce the dosage of pain medication because it is making the patient sleepy. What is the most appropriate answer by the nurse to the caregiver?

"The patient had not slept well because of pain; the patient is resting better with reduced pain." The patient may be exhausted from not sleeping well while in pain; the medication helps to reduce pain and the patient is now able to sleep. The nurse needs to educate the family about pain medication and their side effects. The medication is used to reduce pain and not sedate the patient. Pain medication dosages are adjusted depending on the pain level. Sleepiness in this patient may not be an indication of progression of the disease or the patient "letting go."

A nurse notes that the patient on hospice has a fecal impaction. What should the nurse do first?

Administer a Xanax. The nurse should first administer an antianxiety medication such as Xanax to help the patient tolerate the procedure better. A Fleet enema can be used instead of digital removal. A stimulant laxative should not be administered with an impaction because of the risk of damage to the colon. The nurse should encourage the patient to drink fluids to prevent another impaction.

A nurse is assisting with the selection of goals for the patient on hospice. Which goal(s) would be most appropriate for the patient on hospice?

Alleviating the patient's symptoms. Maintaining patient and family confidence. Involving the patient and family in care planning decisions. The goals of hospice care include alleviating symptoms, maintaining patient and family confidence, and involving the patient and family in care planning decisions. The patient should be encouraged to live life to the fullest versus conserving strength (when appropriate). Curing the patient's disease is not a goal of hospice care.

A nurse caring for a patient in the hospice setting assesses the development of a stage II pressure ulcer on the patient's sacral area. What is the most appropriate nursing intervention?

Apply a skin protector. If pressure ulcers occur, cleaning with normal saline, drying well, and applying a skin protector are helpful measures. Cleansing with hot, soapy water; application of a wet-to-dry dressing; and daily tub baths are not appropriate interventions for a stage II pressure ulcer and can lead to infection and/or further skin breakdown.

A patient has been diagnosed with terminal cancer and has been given a prognosis of 3 months to live. How should the nurse introduce the subject of palliative and hospice care?

As redirection of care. Palliative and hospice care are considered a redirection of care from finding a cure to alleviating the patient's symptoms. It is not a withdrawal of care, a discharge from the primary health care provider's care, or homeopathic medicine used to find a cure.

The nurse is caring for a patient who is terminally ill and finds that the patient is experiencing dyspnea. What nursing interventions should be performed to relieve dyspnea? Select all that apply.

Ask the patient to rate the respiratory effort. Monitor the need for oxygen use by measuring oximetry. Educate the patient on methods to ease respiratory distress. Whenever a terminally ill patient reports dyspnea or shortness of breath, it is necessary to ask the patient to rate the respiratory effort on a scale of 0 to 10. It is also important to monitor the respiratory status of the patient. Monitoring the need for oxygen using oximetry helps in determining the amount of oxygen needed per nasal cannula. Educating the patient on methods to ease respiratory distress helps the patient to breathe well and to improve the respiratory status. Monitoring the heart rate doesn't help in relieving dyspnea. Checking for compliance with medication is a general intervention performed in all terminally ill patients.

To provide effective hospice care, the nurse needs to have an understanding of the goals of hospice care. Which statement appropriately addresses the goals of hospice care? Select all that apply.

Control and alleviate the patient's symptoms Encourage the patient and caregiver to live life to the fullest. Allow the patient and caregiver to be involved in the decisions regarding the plan of care. These statements are appropriate and true at addressing the goals of hospice care. Hospice care provides continuous support to maintain patient and family confidences and reassurances to achieve these goals. Patients on hospice care may continue to have chemotherapy or radiation if that is what the patient desires.

A nurse caring for a patient with cancer knows that which prognosis is necessary for the patient to be admitted into hospice?

Death is likely within the next 6 months. Patients with a prognosis of less than 6 months to live are eligible for admission into hospice. A prognosis of greater than 6 months does not qualify the patient for admission into hospice.

The nurse is caring for a patient and has administered atropine sublingually. What could be the reason for the administration?

Death rattle. Death rattle is a characteristic coarse and loud sound that air makes as it passes through the mucus. It is coarse and loud. It is usually heard due to accumulation of mucus and fluids in the posterior area of the pharynx 24 to 48 hours before death. The anticholinergic drugs such as transdermal scopolamine or sublingual atropine are used to prevent excess mucus production, thus decreasing the death rattle. Atropine is not used in the treatment of dyspnea, anorexia, or constipation. Bronchodilators help in relieving dyspnea. Anorexia can be managed by providing small frequent meals to the patient. Constipation can be relieved with the help of laxatives.

A patient is having trouble with nausea and vomiting after chemotherapy. What is the nurse's most appropriate intervention?

Encourage the patient to eat slowly in a pleasant atmosphere, with relaxation and rest periods after eating. A good way to control nausea is to eat slowly and in a pleasant atmosphere, with relaxation and rest periods after eating. Ineffective pain control is often the reason for nausea and vomiting. The patient should take pain medications routinely. Antiemetics need to be taken routinely as prescribed. A patient should never be forced to eat or drink if there is no desire to; this response may compromise the dignity of the patient.

Which nursing interventions should be performed for a chemotherapy patient reporting nausea? Select all that apply.

Encourage the patient to eat slowly. Encourage the patient to eat sweets. Encourage the patient to verbalize fears. Encourage the patient to relax after eating. Nausea is a possible side effect of chemotherapy and can result from any obstructions, tumor, uncontrolled pain, constipation, and even the smell of food. The nurse should encourage the patient to eat slowly to control nausea. The nurse should encourage the patient to drink liquids to avoid dehydration. If anxiety and fear are causes of nausea and vomiting, verbalizing fears is helpful. The nurse should ask the patient to relax after eating to prevent nausea. Sweet, greasy, spicy, or strong-smelling foods should be avoided in a patient with nausea.

The nurse at the hospice center is caring for a terminally ill patient. What psychosocial intervention by the nurse provides support to the patient and family?

Encouraging reminiscence. The nurse should encourage reminiscence for both the patient and family to provide the ability to attain perspective and enhance meaning. The nurse should not try to explain the impending loss to the family; it may not be acceptable. The nurse should teach about the physical signs of death to the family, and should promote spirituality as well if the patient and family are receptive.

What are the nursing interventions to be performed for pain control in a terminally ill patient? Select all that apply.

Explain the measures to control pain. Monitor for side effects of medications. Ask the patient to rate the pain on a scale of 0-10. Suggest that the patient and caregiver keep a pain diary. The nurse explains various techniques of controlling pain, which include repositioning methods, heat and cold treatments, and transcutaneous electric nerve stimulation. Pain management includes drug therapy, and hence it is important to monitor for side effects of the medication prescribed. It is also important to ask the patient to rate the pain because this informs about the intensity of pain. Nursing interventions to control the pain also include suggesting that the patient and the caregiver keep the pain diary. This helps the nurse understand the status of pain in the patient. It is the responsibility of the primary health care provider to evaluate the cause of the pain.

What risk does the nurse expect for a patient in hospice who is administered prochlorperazine (Compazine)?

Extrapyramidal side effects. Prochlorperazine (Compazine) is an antiemetic. Prochlorperazine (Compazine) causes extrapyramidal side effects, such as acute dystonic reactions, pseudoparkinsonism, or akathisia. It can cause dry mouth in the patient and induce depression in the patient. Anxiety is not a side effect of prochlorperazine (Compazine). However, it is a side effect associated with antidepressants. Hypotension and tachycardia are side effects of droperidol (Inapsine), another antiemetic medication.

Pain control for a hospice patient is best attained through use of long-acting medications. Which are long-acting medications? Select all that apply.

MS Contin OxyContin Duragesic patch These long-acting medications (MS Contin, OxyContin, and Duragesic patch long) provide better pain management and are more convenient for the patient and the caregiver. Lortab is not as strong a narcotic; therefore its effects do not last as long, leading to ineffective pain management. Ibuprofen may be used as adjunctive therapy to assist with pain relief, but as an anti-inflammatory it is not effective enough to control the pain.

Which functions should the nurse coordinator perform for a patient in hospice? Select all that apply.

Manage the patient's care. Assign the primary team for the patient. The interdisciplinary team in hospice is a multiprofessional health team whose members work together caring for a terminally ill patient. The core interdisciplinary team members are the medical director, the nurse coordinator, the social worker, and the spiritual coordinator. The nurse coordinator's responsibility is to manage the patient's care and to explain the service to the patient. The nurse coordinator admits the patient into the hospice and assigns the primary team to take care of the patient. The spiritual coordinator's responsibility is to coordinate and provide spiritual support to the patient. The social worker's responsibility is to evaluate the psychosocial needs of the patient and to assist with counseling in grief issues of the patient.

A patient complains of tingling and burning pain in the extremities. The nurse knows to document this as which type of pain?

Neuropathic pain. Neuropathic pain is often described as tingling or burning. Visceral pain originates from the internal organs. Somatic pain is musculoskeletal pain. Phantom pain is pain the patient experiences as coming from where an amputated limb used to be.

A patient with colon cancer being admitted to hospice care does not have an advance directive. Which elements does the nurse include in the discussion with the patient and family about advance directives? Select all that apply.

Portable Do-Not-Resuscitate (DNR) order. Instruction about life-sustaining treatment. Instructional directive for health care professionals. Durable power of attorney for health care (DPOAHC). At the time of admission to hospice care the nurse should document the presence of an advance directive by the patient. An advance directive is a legal document or directive about the patient's decisions regarding life-sustaining treatment when he or she loses decision-making capacity. Living wills and medical directives such as DNR orders are instructional directives that help health care professionals make the appropriate decision(s) as per the patient's will. A portable DNR order or a DNR order written in advance is an advance directive. A patient can appoint a health-care proxy by providing a DPOAHC regarding their health care to make decisions for the patient in the event of loss of decision-making capacity. An advance directive can be altered once it is filed, but will need to be witnessed again.

A nurse is planning care for the patient with terminal cancer on hospice. How should pain medication be administered for the best possible pain control?

Regularly around the clock. Pain medication should be scheduled around the clock to ensure proper pain control. Medication should also be available on an as-needed basis for breakthrough pain. Nonpharmacologic pain control methods should be used in addition to prescription pain medications for terminal cancer pain.

The nurse is providing hospice care for a patient nearing death who has loud, wet respirations. What intervention does the nurse perform for this patient?

Reposition the patient onto one side. When caring for the patient with loud, wet respirations, the nurse repositions the patient to one side and places a towel under the mouth to collect secretions. Oropharyngeal suctioning is not recommended for loud secretions in the bronchi or oropharynx because it is not effective and may only agitate the patient. Administration of antibiotics is not recommended for a patient for whom death is imminent. Hyoscyamine (Levsin) is generally administered every 6 hours orally or sublingually to dry up secretions.

Who are the members of a core interdisciplinary team? Select all that apply.

Social worker. Nurse coordinator. A core interdisciplinary team develops and supervises hospice care in conjunction with all those individuals involved in the care. The interdisciplinary team is comprised of a social worker and a nurse coordinator in addition to a medical director, and spiritual coordinator. A social worker takes care of the psychosocial needs of the patient, provides counseling, and serves as a resource for community services. The nurse coordinator is a registered nurse who coordinates the implementation of the care plan for each patient. A pharmacist, primary spiritual leader, and bereavement coordinator are the members of the primary hospice team.

While communicating with a patient who is terminally ill, the nurse finds that the patient is experiencing visceral pain. What description by the patient has led the nurse to such a conclusion?

Squeezing pain. Pain that originates from the internal organs is called visceral pain. Patients generally describe this pain by using words such as dull pain, cramping, pressure, or squeezing pain. Neuropathic pain arises from the nerve endings. Tingling, burning, and shooting pains generally have neuropathic origin. Somatic pain arises from musculoskeletal system and is described by words such as stabbing, aching, or throbbing.

A patient suffering from a malignant tumor stops responding to the treatment. The primary health care provider states that curative care is no longer possible. What information does the nurse give to the patient's family members and the patient about hospice admission?

The hospice team will provide support to control the symptoms. Patients who are terminally ill and no longer responding to curative care are admitted into hospice . The hospice team provides palliative care to such patients, which includes measures to control the symptoms and provide emotional support to the patient and the family. The hospice team doesn't continue curative care of the patient who stopped responding to the treatment. It is not advisable to tell the family members and the patient directly about the death, as it may lead to emotional stress. Instead the nurse should explain to them the treatment given to the patient, that the patient has stopped responding to the treatment, and how the hospice team would care for the patient. Patients are not discharged or sent home if there is no hope for treatment or they stop responding to treatment, but they are advised to be admitted to hospice.

The family of the patient who has been on hospice for over 5 months is concerned that reimbursement will end for their mother's care after 6 months. What is the best way for the nurse to respond?

The original process of two physicians attesting to a prognosis of less than 6 months to live will repeat until your mother passes away." For reimbursement for hospice care to continue, two physicians must document the patient's prognosis of less than 6 months to live. Payment does not cease after the first 6 months. One physician's statement of the prognosis is not enough for reimbursement by Medicare. It is not necessary to have three doctors give a prognosis of less than 3 months to live.

The nurse is caring for a patient in hospice who reports anorexia due to stomatitis. The nurse instructs the patient to use oral swabs dipped in water rather than mouthwash. What could be the reason for this instruction?

The patient has oral ulcers. Sometimes anorexia can be due to stomatitis or oral infections. In this case, it is recommended to use sponge-tipped oral swabs dipped in mouthwash to improve oral hygiene. Oral swabs dipped in water are preferred because mouthwash may cause discomfort in patients with oral ulcers. Nausea is not related to the use of oral swabs. Oral swab usage is not an intervention for dry mouth. Artificial saliva is used in patients with dry mouth.

A patient with bone metastasis reports shortness of breath. Which outcomes would indicate that the nursing interventions were effective? Select all that apply.

The patient performs relaxation techniques. The patient has improved respiratory status. The patient performs diaphragmatic breathing. The patient breathes easily while doing exercises. A patient with bone metastasis and shortness of breath requires nursing interventions to improve respiratory status. The nurse should educate the patient about methods such as relaxation techniques and diaphragmatic breathing that will ease respiratory distress. Improved respiratory status, which is indicated by increased oxygen saturation levels and normal rate and depth of breathing, would also indicate that the nursing interventions were effective. The patient being able to perform deep breathing exercises and diaphragmatic breathing independently indicates that the nursing interventions were effective. The ability to breathe easily while doing exercises would also indicate that the nursing interventions were effective. The patient will not need oxygen administration if the nursing interventions are effective.