Davis Advantage - Chapter 5 End-of-Life Care

A 2-year-old has recently been diagnosed with a terminal type of cancer but is not experiencing any severe symptoms of the illness at this time. The mother of the patient is depressed and feels guilt over the illness. She admits to mentally planning the funeral and expecting to be devastated. The nurse identifies the mother as experiencing which stage of grief? 1. Anticipatory 2. Anger 3. Denial 4. Bargaining

ANS: 1 Feedback 1 This is correct. Anticipatory grief occurs before the stages of grief and is common in infant and pediatric death when the family of a patient with a terminal diagnosis prepares for death before the dying process. 2 This is incorrect. Anger concerning death results in feelings of wrath or indignation; it will often manifest as anger toward the disease, the cause of death of the infant or child, or even the medical staff and caregivers of the child. 3 This is incorrect. Following anticipatory grief is denial, which is a refusal to believe that an infant or child is dead or dying. 4 This is incorrect. Bargaining or negotiation is an attempt to create a change in the situation through an agreement for services exchanged.

The nurse is providing care for a pediatric patient who is receiving end-of-life care at the age of 12 years. In addition to the patient, the nurse is caring for the family members from a Middle Eastern culture, including younger siblings of the patient. Which comment by the nurse exemplifies appropriate communication? 1. "Please let me know if you have pain so that I can make you more comfortable." 2. "I know your son is going to heaven and all of you will be together in the future." 3. "Your brother is suffering, and you need to be strong and brave for him now." 4. "I understand you will be ready to move away from this life and on to the next."

ANS: 1 Feedback 1 This is correct. End-of-life communication with the patient needs to be compassionate and developmentally appropriate. The nurse needs to communicate a caring attitude about the patient's pain and comfort status. This comment is appropriate. 2 This is incorrect. When the nurse expresses personal beliefs, the cultural beliefs of the patient and family is violated. 3 This is incorrect. Telling a sibling younger than 12 years of age that their brother is suffering is likely to cause anguish to the sibling. Encouraging the sibling to be strong and brave is suggesting denial of feelings. 4 This is incorrect. When the nurse expresses feelings related to the patient's impending death, the nurse is interjecting personal feelings into the patient's situation; the nurse needs to focus on the patient's and family's feelings.

The nurse assesses the pain level of a school-age patient who is receiving end-of-life care and determines a need for pain medication. The physician has prescribed morphine sulfate to be administered either orally or rectally. For which reason will the nurse decide to administer the medication orally? 1. To prevent the patient from being embarrassed by rectal administration 2. To ensure the pain medication is absorbed as quickly as possible 3. To avoid stimulation of rectal spasms during insertion of the medication 4. To decrease the risk of respiratory suppression

ANS: 1 Feedback 1 This is correct. The administration of medication rectally is likely to cause a school-age client to be embarrassed. When possible, the nurse will prevent psychosocial discomfort as well as physical discomfort. 2 This is incorrect. The oral form of morphine sulfate is effective; however, the rectal route is likely to be absorbed more quickly. 3 This is incorrect. The rectal insertion of morphine sulfate is not likely to stimulate rectal spasms. 4 This is incorrect. The side effects of morphine sulfate are the same regardless of the route of administration.

The nurse is providing end-of-life care to a pediatric patient and family. The nurse understands the need for communicating with the multidisciplinary care team regarding the patient and family needs. For which reason is multidisciplinary communication with the patient's nurse so important? 1. The nurse has the most contact with the patient and family and acts as an advocate and voice for their care. 2. The multidisciplinary team relies on the nurse to provide appropriate education to the patient and family during end-of-life care. 3. As the sole communicator, the nurse can make sure that all members of the multidisciplinary team are equally informed. 4. The patient and family can communicate with the nurse with whom they have built a trusting relationship.

ANS: 1 Feedback 1 This is correct. The nurse has the most contact with the patient and family and acts as an advocate and voice for their care. The nurse can determine effectively which member of the multidisciplinary team should be contacted in order to provide the best care. 2 This is incorrect. The nurse, during end-of-life care, is not expected to provide education to the patient and family; this task is more appropriate for hospice nurses. 3 This is incorrect. The nurse is not the sole communicator during end-of-life care; in addition, not all multidisciplinary team members need to receive the exact same communication. 4 This is incorrect. When the nurse is providing appropriate and effective end-oflife care, the patient and family will build a trusting relationship with the nurse. However, this role as advocate is different than the communication role with multidisciplinary team members.

The pediatric nurse is providing care for a terminally ill patient who is 17 years of age. The patient has been resistant to aggressive chemotherapy because of undesirable side effects. The patient states, "I have finally convinced my parents to sign a DNR order. It is my life, and I should be able to decide how I want to live." Which legal consideration causes the nurse greatest concern? 1. A DNR order can be reversed at any time by the legal guardians. 2. The primary physician can deny a DNR if the patient is a minor. 3. The patient does not understand all aspects of the DNR order. 4. A DNR can be written to provide partial life-sustaining interventions.

ANS: 1 Feedback 1 This is correct. The nurse is aware that the patient is a minor and only legal guardians can determine a minor's DNR status. The patient's sense of satisfaction is the nurse's greatest concern, because legal guardians can reverse a DNR decision at any time. 2 This is incorrect. Primary physicians cannot deny a DNR order just because the patient is a minor. The legal guardians have the right to request the order and the physician has the responsibility to make sure they understand all aspects of the decision. 3 This is incorrect. The minor patient may or may not understand all aspects of a DNR order; this is not likely to be the nurse's greatest legal concern. 4 This is incorrect. It is true that a DNR order can be written to provide partial or limited life-sustaining interventions. This is not the nurse's greatest legal concern.

The nurse is presenting information to pregnant couples about the "safe to sleep" campaign to prevent SIDS. One attendee states, "Babies sleep best on their bellies. What difference does position make?" Which answer by the nurse is best? 1. "Positioning on the back opens the airway fully." 2. "Sleeping face down increases the risk of aspiration." 3. "The most dangerous time is 2 to 4 months of age." 4. "Of greater importance is not using blankets."

ANS: 1 Feedback 1 This is correct. The nurse should always educate parents to put their infants on their backs to sleep to help prevent sudden infant death syndrome by keeping the airway fully open. 2 This is incorrect. Placing the infant face down may increase the risk of aspiration if the infant vomits or spits up. However, the best answer is the one that defends how the parents can avoid the incidence of SIDS, which is the primary cause of unexpected infant death. 3 This is incorrect. The nurse can share that the most vulnerable age for SIDS is between 2 and 4 months of age. However, this does not reinforce the physiological reason why infants need to sleep on their back. 4 This is incorrect. Parents are instructed to keep blankets and other objects that can cause suffocation out of the infant's crib. However, this comment does not reinforce the physiological reason why infants need to sleep on their back.

A pediatric patient with a terminal disease is placed in hospice care. In addition to patient care, which other services provided by a multidisciplinary team will meet the needs of the patient and family? Select all that apply. 1. Social work 2. Child-life specialist 3. Community programs 4. Physician 5. Grief counselor

ANS: 1, 2, 4 Feedback 1. This is correct. Social work ensures that the family's nonmedical needs, such as housing and employer notification, are met. 2. This is correct. The child-life specialist provides age- and developmentally appropriate toys and environment for patient and siblings. 3. This is incorrect. Community programs and support programs will most likely be recommended to the family after the death of the patient. 4. This is correct. The physician leads medical care and orders medications and interventions while providing the patient and family with education regarding the diagnosis. 5. This is incorrect. A grief counselor is most likely to assist the family after the death of the patient.

The parents of a dying child have decided to withdraw medical treatment and allow their child to die peacefully. Which nursing actions will occur after the withdrawal is implemented? Select all that apply. 1. Monitoring equipment is turned off. 2. All invasive lines are disconnected. 3. Periodic validation is sought from the family regarding the decision to end care. 4. A comfortable, peaceful environment is created for the patient and family. 5. The family is provided with undisturbed privacy.

ANS: 1, 2, 4, 5 Feedback 1. This is correct. Monitoring equipment is turned off; when operating, the equipment can be a disturbing distraction. 2. This is correct. Invasive lines and equipment are removed in order to present the patient with an appearance as normal as possible. 3. This is incorrect. The family can decide to reinstate medical care if they desire; however, the nurse does not check periodically to see if the decision for withdrawal of care is changed. 4. This is correct. The patient's linens can be changed or straightened, lights can be dimmed, and the patient placed in a comfortable position. Chairs and other desired accommodations are provided for the family. 5. This is correct. In order to ensure uninterrupted privacy, the door should be closed and the family left undisturbed unless they seek assistance.

The nurse is providing end-of-life education to parents of a child diagnosed with a terminal illness. Which topics of education are important for the nurse to provide? Select all that apply. 1. Explain how the progression of the disease will affect their child. 2. Describe the physical changes that will occur during the dying process. 3. Suggest several funeral homes to be contacted before death. 4. Explain that pain management will interfere with communication. 5. Describe what to expect after death including how the child will look.

ANS: 1, 2, 5 Feedback 1. This is correct. The nurse needs to cover the topic of how the progression of the disease will affect their child. This information will help the parents to distinguish between expected and unexpected changes. 2. This is correct. The nurse needs to cover the topic of the physical changes that will occur during the dying process. Some topics will include skin alterations, breathing alterations, altered consciousness, and changes in verbalization. 3. This is incorrect. End-of-life education does not involve providing a list of funeral homes to contact prior to the death. Families may have a funeral home in mind, and planning before the death may be offensive to some families. 4. This is incorrect. Pain management may or may not interfere with communication. The parents need to be encouraged to talk to their child even when two-way communication is not possible. 5. This is correct. The nurse needs to cover the topic of what to expect after death. Some families are concerned that the physical appearance is grossly altered. The parents also need to know about how the body will be cared for and about making funeral arrangements.

The nurse works on a pediatric unit that allows parents to remain in the room if the patient is coded. The nurse is aware that having persons in the room other than medical personnel can present safety issues. Which concerns are important to address? Select all that apply. 1. The possibility of an accidental shock during cardiac shock delivery 2. The possibility of accidental contamination of sterile fields and procedures 3. The possibility of medical staff being blocked from access to the patient 4. The possibility of medical staff being interrupted by emotional verbalization 5. The possibility of overcrowding interfering with needed medical equipment

ANS: 1, 3, 5 Feedback 1. This is correct. It is important for the nurse to be concerned about the safety of the family. The concern about family members not touching the bed or medical equipment during cardiac shock delivery will need to be addressed. 2. This is incorrect. Most codes are not run in a sterile location. It is unlikely that the presence of a family member would cause more contamination than other members of the code team. 3. This is correct. For the safety of all involved, it is important to ensure that family members are not in the way of medical staff or interfere with treatment. 4. This is incorrect. It would be unexpected for emotional verbalization from a family member to interrupt the medical staff. A staff member should always be with the family to monitor behaviors and provide information. 5. This is correct. For the safety of all involved, it is important to ensure that family members are not in the way of medical equipment.

The nurses on a unit that cares for terminal pediatric patients wish to implement a change in facility policy to allow parents/guardians to remain during a patient code. Which is the most powerful reason that nurses can present to administration? 1. Family-centered care can be continued during a very stressful situation. 2. The family knows everything possible was done to save the patient. 3. The family experiences greater communication and decreased confusion. 4. Family may desire to stay during specific interventions that seem inappropriate.

ANS: 2 Feedback 1 This is incorrect. Family involvement in pediatric code situations provides family-centered care during a very stressful situation. Without additional planning and discussion, this is not the most powerful reason for the nurses to present to administration. 2 This is correct. Having family stay during a code can be positive because the family knows everything possible was done to save the patient. This is the most powerful reason for the nurses to present to administration. 3 This is incorrect. Continuation of family-centered care in pediatric code situations is to create greater communication and decrease confusion for the family. However, this is not the most powerful reason for the nurses to present to administration unless there is strong support from other members of the multidisciplinary team members. 4 This is incorrect. The family may attempt to be at the bedside, which can be inappropriate with specific interventions; an example would be open-chest procedures. This point would require discussion and the development of guidelines.

A 16-year-old patient is approaching the terminal stage of a brain tumor. The nurse notices the patient is calling friends and making plans for a social gathering several months away. When friends are present the patient assures them of a full recovery because of a new doctor. The nurse recognizes the patient is experiencing which stage of grief? 1. Acceptance 2. Denial 3. Anger 4. Bargaining

ANS: 2 Feedback 1 This is incorrect. Statements of understanding of the loss, positive outlook, and discussion of the future are indicative of acceptance. 2 This is correct. Unwillingness to accept the diagnosis and lack of trust in medical staff are indicative of denial. 3 This is incorrect. Anger or aggression toward staff or family members and verbal arguments and confrontations are common during the grief stage of anger. 4 This is incorrect. Reliance on a higher power to prevent death and believing that promises of future behavior will prevent death are indicative of bargaining.

The nurse works in a pediatric hospice unit in an acute care facility. The nurse is currently providing care to an infant. Which assessment tool does the nurse use to identify the infant's level of pain? 1. Faces scale 2. FLACC 3. Visual analogy scale 4. NIPS

ANS: 2 Feedback 1 This is incorrect. The faces scale is only for patients aged 3 years and older; the child must be developmentally able to read and recognize faces drawn with various levels of painful expressions. This pain scale asks the child to choose the face that best represents his or her pain level. The patient is too young for this scale. 2 This is correct. The FLACC scale (faces, legs, activity, cry, consolability scale) is used for newborn to 7 years. This assesses the patient's facial expression, leg positioning and flexion, activity level, crying level, and consolability. This is the appropriate scale for this patient. 3 This is incorrect. The VAS is for children aged 7 years and older who have the developmental ability to use the traditional pain scale based on numbers 0 to 10 for pain rating. The patient is too young for this scale. 4 This is incorrect. The neonatal and infant pain scale (NIPS) is for newborns. This assesses the newborn's cry, facial expression, respiratory pattern, position and flexion of the arms and legs, and level of alertness. The scale is better suited for newborns.

With endorsement from the family, the physician initiates hospice care for an adolescent patient who is terminally ill. For which family expectation about hospice care will the nurse provide additional information? 1. The patient will have a graceful, natural death. 2. The patient will die in the hospital. 3. Compassionate care will be focused on patient comfort. 4. The family can be involved in care as much as desired.

ANS: 2 Feedback 1 This is incorrect. There is no need to provide additional information if the family understands that a hospice goal is for the patient to have a graceful, natural death. 2 This is correct. If the family anticipates that the patient will die in the hospital, the nurse can provide additional information that hospice care can also take place in the patient's home with visiting nurses and care aides. Some hospice groups have an independent facility. 3 This is incorrect. There is no need to provide additional information if the family understands that hospice will provide compassionate care focused on patient comfort. 4 This is incorrect. There is no need to provide additional information if the family understands they can be as involved as much as desired in the patient's care.

The nurse is providing care for a pediatric patient and family during the time when death of the patient seems imminent. The family is of American Indian culture and has summoned tribal members to come and chant and pray at the bedside. Which behavior by the nurse is culturally correct? 1. Move the patient, family, and tribal members to an isolated location. 2. Ask the family to respect other patients by keeping the volume of chanting low. 3. Ask if the family has any additional needs, close the door, and provide privacy. 4. Call the nursing supervisor and ask for assistance in managing the situation.

ANS: 3 Feedback 1 This is incorrect. Moving the family to an isolated location can be interpreted as disrespect for the patient's and family's culture. 2 This is incorrect. Asking the family to respect other patients by keeping the volume of chanting low can be interpreted as disrespect for the patient's and family's culture. 3 This is correct. Cultural considerations for pediatric end of life include respecting the cultural beliefs of the family and patient. Providing culturally competent care requires the nurse to incorporate the cultural beliefs of the family and patient into daily care. The spiritual needs of family and patient require the nurse to incorporate the spiritual beliefs of the family and patient into daily care. 4 This is incorrect. There is no reason to call the supervisor, and there is no situation to manage. The nurse can effectively provide the family cultural support by closing the patient's door and giving the family and tribal members' privacy.

The nurse is providing care for a pediatric patient who is 11 years of age. The patient is diagnosed with an aggressive form of cancer and is scheduled to begin chemotherapy. The patient tells the nurse, "I think I am going to die, but I also think I will get much sicker first." Which communication by the nurse is most appropriate for this patient? 1. Explain to the patient the importance of maintaining a hopeful outlook. 2. Encourage the patient to ask the doctor to explain what is going to happen. 3. Use basic terms to explain the disease progression and side effects of treatment. 4. Provide information about the different options that can be considered for the patient.

ANS: 3 Feedback 1 This is incorrect. The patient is 11 years of age and has stated expectations related to the medical diagnosis. Encouraging the patient to maintain a hopeful outlook does not address the thoughts and concerns that already exist. 2 This is incorrect. Nurses have the capability to answer questions about the patient's condition and treatment; it is unnecessary to delay meaningful communication until the physician can answer. The nurse can encourage the patient to also talk with the physician and parents, but information does not need to be delayed. 3 This is correct. Nursing education to the pediatric patient in this scenario should include age-appropriate information about the disease and treatment. 4 This is incorrect. The patient is 11 years of age and unable to contemplate and decide about the medical treatment. The parents or legal guardian are considered to be the decision makers.

The coroner is informed of the unexpected death of an infant at 3 months of age. The infant died during the night in the home of the parents. Which expectation does the nurse have regarding follow-up to the infant's death? 1. The hospital will pay for an autopsy if requested by the physician. 2. The coroner's office will not charge the parents if they request an autopsy. 3. The coroner can legally request an autopsy without the parent's consent. 4. The parents must give consent before an autopsy is performed for any reason.

ANS: 3 Feedback 1 This is incorrect. The physician may request an autopsy if the patient's cause of death is not known; however, the cost of the autopsy is covered by the coroner's office if the coroner agrees. The hospital is unlikely to be responsible for the cost. 2 This is incorrect. Families may request an autopsy if they wish to know the exact cause of the death of their child; if the coroner does not agree that an autopsy needs to be performed, the family may be responsible for the cost of the autopsy. 3 This is correct. The coroner has the legal right to request an autopsy in any suspicious or unexpected death and does not need consent of the family if it is considered legally necessary. 4 This is incorrect. The consent of the family is not needed if the autopsy is considered legally necessary, as in an unexpected or suspicious death

The nurse works on a pediatric unit where patients are on life support. Frequently, death is delayed for the benefit of organ donation and procurement. Which protocols for organ donation and procurement does the nurse always need to follow? Select all that apply. 1. The nurse approaches the family of a patient who is a viable candidate. 2. The best matched pediatric patients on the transplant list are notified. 3. The consent for organ donation can be given only by legal guardians. 4. The facility pediatric surgical team will procure the organs for transplant. 5. The parents only can accompany the patient to the operating room.

ANS: 3 Feedback 1. This is incorrect. When a child is considered a viable candidate for organ donation, the family is approached by an organ donation approach team. This multidisciplinary team of health-care providers and ancillary staff is specially trained in approaching families to request that they donate the patient's organs. 2. This is incorrect. Once consent is given, blood is drawn from the patient to determine the patients on the transplant list who are the best match for the organs available. However, pediatric organs can be transplanted into pediatric or adult patients. 3. This is correct. Consent is needed from the legal guardians for organ donation. 4. This is incorrect. Procurement of organs is commonly done by the transplanting surgical team. The team travels to the site of the organ donor, and the patient is taken to the operating room to remove the organs. 5. This is incorrect. Parents and family members should say goodbye to the patient before transfer to the operating room; the patient will die in the operating room.

The nurse is presenting information to a group of parents regarding pediatric safety and the most common causes of death. One attendee states, "I am so happy that my youngest child is now 16." Which information does the nurse present in response to this comment? 1. The 16-year-old child is at high risk for death related to cancer. 2. Life expectancy with congenital or genetic defects is 13 to 19 years. 3. Adolescents between 5 and 19 years of age most commonly die from suicide. 4. Between 15 and 19 years of age the death rate is 45.5 deaths/100,000.

ANS: 4 Feedback 1 This is incorrect. Cancer is listed as a common cause of pediatric patients between the ages of 5 and 14 years. 2 This is incorrect. Death from congenital malformations, deformations, and chromosomal abnormalities most commonly occurs between 1 and 4 years of age. 3 This is incorrect. Between the ages of 5 and 19 years, suicide is listed as one of the leading causes of death. However, suicide is not singled out as the primary cause of death in this age group. 4 This is correct. Between 15 and 19 years of age the death rate is 45.5 deaths/100,000. This is the pediatric group with the highest incidence of death. The most common causes are accidents, suicide, and homicide.

The parents of a toddler, diagnosed to be in the end stage of a terminal illness, are concerned about how to manage pain without the sedation effects of pain medications. Which suggestion by the nurse is likely to meet the needs of both the parents and the patient? 1. Encourage the parents to bring favorite toys and books. 2. Initiate playtime in the playroom with other patients. 3. Provide age-appropriate videos for patient distraction. 4. Suggest a parent hold the patient and perform gentle massage.

ANS: 4 Feedback 1 This is incorrect. The toddler in the end stage of terminal illness may or may not be receptive to favorite toys or books. Holding and soothing are likely to be more effective. 2 This is incorrect. It is unlikely that a toddler in the end stage of terminal illness will be willing or able to play with other children. Holding and soothing are likely to be more effective. 3 This is incorrect. The toddler in the end stage of terminal illness may or may not be effectively distracted by age-appropriate videos. Holding and soothing are likely to be more effective. 4 This is correct. The parents have expressed a desire for pain management without the sedation effects of pain medication. The unspoken need of the parents is to have the ability to interact with their child and still achieve pain management. When the nurse suggests that a parent hold the patient and perform gentle massage, the needs of both the patient and parents are being met; the suggested actions will promote relaxation and potentially decrease pain