Chapter 43 Loss, Grief, and Dying

The nurse provides postmortem care for a client who is not undergoing an autopsy. To achieve the desired outcome of this procedure, which nursing actions should be included? Select all that apply.

Remove any tubes and replace soiled dressings. Place an identification tag on the client's ankle. Provide emotional support to the client's family. Ensure the death certificate has been signed.

The hospice nurse is visiting a new client. Which assessment questions are appropriate for the nurse to ask a client who has a terminal illness? Select all that apply.

"Please describe what you have been told about your condition." "What community resources might be of help to you?" "How well do you think those around you are coping?" "Have you had any previous experiences with the death of someone you love?" Explanation: Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the client's and family's knowledge, perceptions, coping strategies, and resources. Interview questions for these areas would include the following: adequacy of knowledge base ("describe your condition"), perceptions ("previous experience with death of someone you loved"), adequacy of resources ("community resources"), and adequacy of coping ("those around you coping"). Determining if a client has a will to distribute personal property is not a priority assessment for the nurse.

The new hospice nurse is reviewing the concepts of loss and grief with the preceptor. Which statement leads the preceptor to believe that the nurse has an understanding of grief and loss?

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." Explanation: Normal expressions of grief may be physical, emotional, social (feeling detached from others and isolating oneself from social contact), and spiritual. Grief is an internal emotional reaction to loss and occurs with loss caused by separation (e.g., divorce) or by death. Clients lamenting their loss of youth are demonstrating a type of perceived loss, which is intangible to others. Situational losses are experienced as a result of unpredictable events; a child going to college would be a maturational loss for the parent.

A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?

Contact the organ procurement team to discuss organ donation with the spouse. Explanation: The organ procurement team should be contacted as soon as possible to talk with the client's spouse. This discussion cannot wait, as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined. The organ procurement team is specially trained to have these kinds of conversations.

When planning care for a 55-year-old male client with newly diagnosed terminal pancreatic cancer, which nursing diagnosis would be most appropriate?

Death Anxiety Explanation: The data the nurse collects about how a client or the client's caregivers are responding to an actual or impending loss or to impending death may support several different nursing diagnoses. Death Anxiety is common when the diagnosis is new and is related to inability to predict how the last stage of illness will play out. Coping mechanisms are important in the dying process and will need to be assessed to determine their adequacy. Failure to Thrive is not appropriate for this client and his medical diagnosis. Impaired Comfort may be appropriate but is not as important as Death Anxiety at this time due to the newness of the client's diagnosis.

The hospice nurse is visiting the wife of a client who died 10 months ago. The wife states, "My life is meaningless since my husband died." The nurse recognizes that the client is in which stage of grief?

Disorganization Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of deceased, be comfortable when remembering the deceased, and return to previous level of ability.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness. Explanation: Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, on the other hand, may be given at any time during a client's illness, from diagnosis to end of life. Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers.

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

Ineffective coping related to failure of previously used coping mechanisms Explanation: The nursing diagnosis best supported by the data is Ineffective coping. Defining characteristics include poor coping skills with activities of daily living as evidenced by unkempt appearance, eating poorly and losing weight, and client statement. Death anxiety refers to an impending death or thoughts of death. Ineffective denial refers to denying the reality of the situation. Decisional conflict refers to inability to make decisions.

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

Inpatient pain management for hospice patients is covered by Medicare. Explanation: Inpatient pain management is covered by Medicare as are any other Medicare-covered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain, hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply.

Irregular respiratory rate Restlessness Bowel incontinence Cyanosis of dependent areas

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation. Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?

The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." Explanation: Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.

When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response?

This must be very difficult for you." Explanation: The nurse should use statements with broad openings, such as "This must be difficult for you," to allow the client to continue expressing concerns and to acknowledge the client's feelings. This facilitates communication and allows the client to choose the topic or manner of response during this stage of the grieving process. Assuming the client is angry and sad or indicating that this is "a terrible diagnosis" is not an appropriate way to promote coping. The nurse should automatically assume a spiritual leader is desired.

The nurse is taking care of a client who was hospitalized for an ulcerative colitis exacerbation. Recently, the client's parent died from colon cancer. Which question would be essential to ask this client at the start of the assessment of her loss reaction?

What type of relationship did you have with your parent? Explanation: When assessing a client for a reaction, both physically and psychologically, to loss, it is important to get a sense of what part the deceased person played in the client's life. If she was not close to her father, the impact might not be so great. On the other hand, if he was an important person in her life, her response might be greater. Other things to initially ask about include whether the loss was expected and whether or not the client feels a sense of responsibility for the loss.

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on his or her own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational

a, b, c. The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is loss that is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow.

a, b, f. Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life), that make up the outward expressions of grief. A diagnosis of cancer and the coroner's pronouncing the patient's death are not behaviors of the family during a period of mourning. Arranging for hospice care would not be an expression of mourning.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? a. The nurse leaves the patient in a sitting position while the family visits. b. The nurse places identification tags on both the shroud and the ankle. c. The nurse removes soiled dressings and tubes. d. The nurse makes sure a death certificate is issued and signed.

a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? a. The patient b. The patient's daughter c. The patient's health care provider d. The ethics consult team

a. Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilities unless she asks them to do this. The ethics consult team is not a decision-making body; it can make recommendations but has no authority to order anything.

The nurse is discussing end-of-life decisions with a patient who has terminal cancer. Which statements describe the patient's options? (Select all that apply.) a. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. b. In a living will, a patient appoints an agent that he or she trusts to make decisions if he or she becomes incapacitated. c. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. d. The status of advance directives varies from state to state. e. Nurses are legally responsible for arranging for a durable power of attorney for all terminal patients. f. Legally, all attempts must be made by the health care team to resuscitate a terminal patient.

a. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. c. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. d. The status of advance directives varies from state to state. Explanation: Advance directives, including living wills, helps the patient to make decisions concerning their end-of-life care. Appointing an agent for care involves identifying a durable power of attorney for healthcare, which is the responsibility of the patient, family, or significant others. If a patient has advance directives, resuscitation is not warranted.

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Yet, nurses may be confronted by patients who seek assistance in ending their lives and must be prepared to respond to the request: "Nurse, please help me die...."

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse could suggest that the husband speak to his wife's health care provider about which type of order? a. Comfort Measures Only b. Do Not Hospitalize c. Do Not Resuscitate d. Slow Code Only

a. The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order. The wife would want all aggressive treatment to be stopped at this point, and all care to be directed to a comfortable, dignified death. A Do Not Hospitalize order is often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive treatment. A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. A Slow Code means that calling a code and resuscitating the patient are to be delayed until these measures will be ineffectual. Many health care institutions have policies forbidding this, and a nurse could be charged with negligence in the event of a Slow Code and resulting patient death.

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? a. Acceptance b. Anger c. Bargaining d. Denial

a. The patient's statement reflects the acceptance stage of death and dying defined by Kübler-Ross.

Which factors affect the grieving process? Select all that apply. a. meaning of loss b. determination of loss c. circumstances of loss d. personal stressors e. sociocultural resources

a. meaning of loss b. circumstances of loss d. personal stressors e. sociocultural resources Explanation: Factors affecting grieving include meaning of loss, circumstances of loss, religious beliefs, personal resources and stressors, and sociocultural resources and stressors.

A patient tells a nurse that he would like to appoint his daughter to make decisions for him should he become incapacitated. What should the nurse suggest he prepare? a. POLST form b. Durable power of attorney for health care c. Living will d. Allow Natural Death (AND) form

b. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A Physician Order for Life-Sustaining Treatment form, or POLST form, is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. The living will is a document whose precise purpose is to allow people to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. Allow natural death on the medical record of a patient indicates the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient.

A nurse is caring for terminally ill patients in a hospital setting. Which nursing action describes appropriate end-of-life care? a. To eliminate confusion, the nurse takes care not to speak too much when caring for a comatose patient. b. The nurse sits on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient. c. The nurse refers to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father. d. The nurse tells a dying patient to sit back and relax and performs patient hygiene for the patient because it is easier than having the patient help.

b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body, and many patients retain a sense of hearing almost to the moment of death; therefore, nurses should explain to the comatose patient the nursing care being given. The nurse should address caregiver role endurance by actively listening to family members. Because it is good to encourage dying patients to be as active as possible for as long as possible, it is generally not good practice to perform basic self-care measures the patient can perform simply because it is "easier" to do it this way.

A nurse is visiting a patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries, and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family. Which response by the nurse would be most appropriate? a. "You can't be feeling this way. You know you are going to die." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll be all right; who knows how much time any of us has." d. "Tell me about your pain. Did it keep you awake last night?"

b. This response by the nurse validates that what the patient is saying has been heard and invites him to share more of his feelings, concerns, and fears. The other responses either deny the patient's feelings or change the subject.

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? a. "Oh, don't worry about that now. You need to sleep." b. "What seems to be concerning you the most?" c. "I have talked to your wife and she told me she will be fine." d. "I'm not qualified to advise you, I suggest you discuss this with your wife."

b. Using an open-ended question allows the patient to continue talking. An open-ended question, such as, "What seems to be concerning you the most?" provides a means of encouraging communication. False reassurances are not helpful. Also, the patient's feelings and restlessness should be addressed as soon as possible.

A client was recently in a motor vehicle accident, which resulted in an amputation of the right leg. The client is withdrawn, doesn't want to get out of bed, and has been crying a lot. What behaviors is the client demonstrating?

bereavement Explanation: The client is exhibiting a symptom of bereavement that includes emotional, physical, social, and cognitive responses

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement. Explanation: Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? a. Inform the family that there is no need for them to wash the body since the mortician typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. c. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? a. Somatic grief b. Anticipatory grief c. Unresolved grief d. Inhibited grief

c. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Somatic grief is not a classification of grief, rather somatic symptoms are the expression of grief that may occur with inhibited grief. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place.

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document? Grieving Ineffective Coping Caregiver Role Strain Powerlessness

c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided. The other diagnoses do not fit the assessment data.

A widow has just returned home from the funeral of her husband. She feels alone in her home. Her family has left to go back to their home in another area of the country. What stage of Engel's model does this represent?

developing awareness Explanation: Developing awareness occurs as the reality and meaning of the loss penetrate the person's consciousness.

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.

expression of feelings management of pain use of coping strategies

A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that:

hospitals are mandated to notify transplantation programs of potential donors. Explanation: The scarcity of organs has resulted in legislation mandating hospitals and other health care agencies to notify transplantation programs of potential donors. New protocols allow the retrieval of organs from non-heart-beating cadavers. The family of a deceased client may decide to donate the organs, and a donor card is not necessary in this circumstance. Attention to optimal client and family care at the time of life-sustaining therapy withdrawal should remain the nurse's priority in care.

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

leaving the wife's room and belongings intact Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond 3 years.

A client has been declared brain dead following a motor vehicle accident. What assessment data would the nurse anticipate?

no ocular movement Explanation: All brainstem reflexes would be absent (including pupillary response, corneal reflex, ocular movements). The respiratory drive would be absent.

In the Parkes model, a person uses denial as a psychological defense in the stage of:

numbness. Explanation: In the numbness stage, which is usually brief, trauma so overwhelms the bereaved survivor that he or she must use denial as a psychological defense.

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

specify the treatment measures that the client wants and does not want. Explanation: Living wills provide instructions about the kinds of health care that should be used or rejected under specific circumstances. The management of an individual's estate is specified in a will, not a living will. It is not legal for a living will to make provisions for active euthanasia. A living will may or may not include reference to organ donation, but normally this is addressed in a separate, specific consent card or document.