End of Life Care
A patient with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first?
Morphine sulfate 5 to 10 mg sublingually as needed Morphine sulfate is the standard treatment for the dyspneic patient who is near death. Albuterol, oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.
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 as 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 well now because pain is reduced." 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."
The nurse is caring for a patient near death who has loud, wet respirations. Which interventions would be most appropriate for the patient to relieve dyspnea? Select all that apply.
Administer atropine solution 1% sublingually. Place a small towel under the patient's mouth. Reposition the patient to one side on the hospital bed. Atropine solution should be administered sublingually every 4 hours to a patient with loud, wet respirations. Atropine helps to dry up secretions. A small towel should be placed under the patient's mouth to collect secretions. The patient should be repositioned to one side on the bed to reduce gurgling. Assessing for infections in a patient near death would not be a priority action. Oropharyngeal suctioning should not be performed in a patient with loud, wet respirations as it is often not effective and it may result in agitation.
Which condition or disorder puts a patient at risk for seizure activity near death?
Brain tumor The patient with a brain tumor is likely to have seizure activity when close to death. Patients with lung cancer and heart failure are at high risk for respiratory distress and dyspnea. The patient with neck cancer is at risk for hemorrhage as tumors are near the major arteries.
What are the intended purposes of massage therapy for the dying patient? Select all that apply.
Decrease pain Enhance dignity Promote relaxation Massage is a popular complementary therapy for patients at end of life. Massage decreases pain in patients with cancer. Daily massage helps the patient feel well and enhances dignity. Patients are relaxed and find peace when massage is incorporated into the palliative plan of care. Massage does not decrease nausea or reduce the need for analgesics. Pain medication is given to the patient round the clock for pain relief.
Which interventions should be performed for a terminally ill patient to control the symptoms of severe distress? Select all that apply.
Discontinue opioids if the patient has oliguria. Give soft foods and liquids if the patient has dysphagia. Discontinue benzodiazepines if the patient develops delirium. Opioids should be discontinued when the patient is oliguric because the kidneys cannot excrete opioid metabolites from the body. This may lead to delirium in the patient. Soft foods and liquids should be given if the patient has dysphagia as liquids may be easily swallowed. Delirium is the adverse effect of benzodiazepines. So, benzodiazepines should be discontinued if the patient develops delirium. Oropharyngeal suctioning should not be performed as it causes agitation in the patient who has wet secretions. Oxygen therapy should not be discontinued even when the oxygen saturation is 90%, as the patient is experiencing dyspnea.
The nurse is caring for a patient who has a POLST (physician orders for life-sustaining treatment). What is a POLST?
A document where additional treatments in case of cardiac or pulmonary arrest are ordered A POLST is an advanced directive in which documentation for additional treatments in case of cardiac or pulmonary arrest are ordered by the patient's physician. A POLST follows the patient across all healthcare settings. A portable DNR order is a state-designated, signed wallet card that is completed before the patient is admitted to the hospital. Like the POLST, a portable DNR follows the patient across healthcare settings. The patient may also wear a special DNR bracelet or necklace.
While caring for a terminally ill patient, the nurse finds that the patient has dysphagia, dehydration, and dry lips. What action should the nurse take?
Apply emollient to the patient's lips. Emollients should be applied to the patient's lips to promote comfort and prevent dryness of the lips. As the patient has dysphagia, the nurse should not give mashed food to the patient. A liquid diet also should be stopped, as the patient is unable to swallow. IV fluids should not be given to a terminally ill patient as this may increase respiratory secretions, increased gastric secretions, nausea, vomiting, edema, and ascites.
Withdrawing or withholding life-sustaining therapy, formerly called passive euthanasia, involves what?
Discontinuing therapies that might prolong the life of a person who cannot be cured by the therapy. Withdrawing or withholding life-sustaining therapy involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. Withdrawal of treatment does not directly cause the patient's death. Voluntary active euthanasia is an act by which the causative agent or treatment in the death of a patient is administered directly by another. Ending the patient's life without the patient's consent is involuntary active euthanasia. Physician-assisted suicide is a practice whereby the health care provider provides a medication to the patient knowing that the patient will use it to commit suicide.`
The nurse caring for a dying patient encourages the family to include the patient in their conversation at the bedside. How does this action help the patient?
Fosters a sense of communication between the patient and caregiver. Although patients nearing death are usually withdrawn from the external environment, it is believed that the sense of hearing remains intact until death. When the family includes the patient in their conversation, it fosters a sense of communication between the patient and caregiver. A spiritual assessment of the patient may encourage the patient to seek spiritual assistance and withdraw from worldly thoughts. Speaking to the patient is not meant to nurture hope of recovery in the patient.
A patient with terminal bone cancer passes away under hospice care. The nurse explains to a team member that the patient had a good death. Which activity related to the patient's death supports the nurse's statement?
The patient and the family had been mentally prepared for the departure. A good death is one in which the deceased and the family members are mentally prepared for the death, and the patient's death is in agreement with the family members. This helps reduce the emotional pain associated with the loss. In an ideal situation, the patient's family should be with the patient for a good death; a bad death involves the patient being abandoned. When in hospice care, the curative treatments are stopped. A good death would include adequate pain-relieving measures to promote the patient's comfort.
The nurse is caring for a Jewish patient in the hospice center. What is this patient's likely attitude and belief regarding terminal illness?
The patient should not be left alone. As per Jewish law, a person who is extremely ill and dying should not be left alone. A Christian patient may forego treatment if it is morally permissible, and may also receive the sacrament of the sick administered by a priest. A patient of Islamic faith may want to lie facing Mecca during the last days of life.
When does the nurse notify the medical examiner about the death of a patient?
The patient's death is suspicious and unexpected. The nurse informs the medical examiner about the death of a patient if the death was suspicious and unexpected. If the patient was in a hospice program and died at home, the family calls the hospice. If the patient died at home as expected, emergency assistance is not notified or needed. If the patient died at the hospice center, the nurse or the health care provider performs the pronouncement and completes the death certificate.
The registered nurse is observing a student nurse providing a massage to a patient with spinal cancer. What recommendation should the registered nurse give to the student nurse?
"Massage tissues not undergoing radiation therapy." The registered nurse should advise the student nurse not to massage over the tissue undergoing radiation therapy to avoid additional pain and discomfort for the patient. The registered nurse should advise the student nurse to use light pressure, especially for cancer patients. Patients who are severely weak, arthritic, or in an advanced disease stage, may not tolerate extensive massage; they would prefer to massage only on specific places. For others, an extensive massage is recommended. The registered nurse should advise the student nurse not to massage over the damaged tissue to avoid further pain and discomfort.
A dying patient says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond?
"Tell me more about that." A response such as, "Tell me more about that," acknowledges the patient's spiritual pain and encourages verbalization. "Don't worry, God will forgive you" assumes that the patient is religious and minimizes the patient's concerns; it gives false reassurance and is a nontherapeutic response. Saying that it's nothing to worry about minimizes the patient's concerns and is a nontherapeutic response; it shuts the patient off from expressing his or her concerns. Asking why the patient is afraid and what he or she did wrong assumes that the patient did something wrong, which may not be the case. "Why" questions are never considered to be therapeutic because they place patients on defense; they often stop communication.
Arrange in order the pathophysiological events that take place during the dying process.
1. Inadequate blood supply to body tissues 2. Occurrence of anaerobic metabolism 3. Release of toxic metabolites in vital organs 4. Multiple organ failure 5. Cardiac arrest Inadequate blood supply to body tissues leads to unmet oxygen demand. It stimulates anaerobic metabolism leading to acidosis, hyperkalemia, and tissue ischemia. This results in release of toxic metabolites in the vital organs such as the kidneys and the liver, which may result in organ failure causing cardiac arrest.
A patient with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do?
Administer prescribed medications to relieve the patient's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor patients for therapeutic and adverse medication effects; the administration of prescribed medications to the patient 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 dying patient exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the patient's last bowel movement was yesterday evening. What does the nurse do first?
Administers an analgesic Agitation may be indicative of pain, which must be addressed in the dying patient. Arranging for a consultation with a counselor is not the priority in this situation. The dying patient's metabolism has slowed, so assessing for impaction may not be necessary. The Foley catheter should not be changed, but the tubing should be assessed to ensure that there are no kinks.
A patient with a terminal illness is near the end of life. The patient refuses to eat or drink anything. To respect the patient's wishes, the nurse should intervene when the patient's caregiver performs which actions? Select all that apply.
Coaxes the patient to have fluids, such as juices Requests an order to give intravenous fluids When near the end of life, the patient should be allowed to die peacefully without performing unnecessary interventions. The nurse should respect the patient's last wishes and should not push the patient into eating or drinking. Intravenous fluids administration is not needed near the end of life because it could be stressful, painful, and uncomfortable for the patient. If the patient chooses to not eat or drink, the patient should not be forced to do so. Forcing the patient can cause stress and discomfort in the patient. Offering small sips of water at frequent intervals helps keep the patient's oral cavity hydrated. Applying moist swab sticks to the lips also helps prevent dryness of the mouth.
The nurse recognizes signs and symptoms of depression in an 80-year-old patient who is dying from metastatic breast cancer. What does the nurse do initially for this patient?
Collaborates with the end-of-life (EOL) care team to manage these feelings in the patient Behaviors should be assessed and treated with the collaboration of the EOL care team. The nurse may be instrumental in performing a "depression" screening. Feelings of depression—hopelessness, helplessness, unhappiness—are not part of the aging process or the process of dying; they should be aggressively treated. These feelings should not only be documented and monitored, but also should be acknowledged as not a normal part of the dying process and should be treated with psychotherapy or medications or both. Inadequate analgesic pain control is one of the most noted and critical problems, especially in older adults. This scenario would not be a reason for opioid administration to be reduced; such an action is harmful to the patient.
The nurse is coordinating interdisciplinary palliative care interventions for the dying patient. Which goal is the nurse seeking to meet?
Facilitating a peaceful death for the patient Facilitating a peaceful death for the patient 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 patient needs is a goal of palliative care, but it is not always possible to meet all of the patient's needs (e.g., to prevent death or lengthen life).
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.
Instruction about life-sustaining treatment Instructional directive for health care professionals Portable Do-Not-Resuscitate (DNR) order 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 dying patient cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do?
Place the patient in a side-lying position so secretions can drain. Placing the patient 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 patient in a high Fowler's position is ineffective in helping the patient who has lost the ability to swallow; the danger of choking and aspiration would increase. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying patient.
A hospice patient has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant?
Removing or cutting all IV lines or tubes according to the hospice policy Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel (UAP). Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.
A hospice patient becomes too weak to swallow. What does the nurse do initially to increase the patient's comfort?
Teaches the family how to provide oral care. Because the oral mucosa will become dry, family members should be taught how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and fluids can be given through an IV line, these are generally considered to increase discomfort by prolonging the patient's suffering. Aspiration is not a concern in terminally ill patients, because fluids are not given orally to patients with decreased swallowing.