NUR 106 - Ch 43 Loss, Grief, and Dying

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs

period during which a person learns to accept grief

Mourning

The caregiver of a client who is terminally ill is becoming short tempered with the client and states, "I just can't take this anymore." Which nursing response is most appropriate?

"Have you considered respite care so that you can rest for a few days?"

A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?

"Have you gone through and donated your spouse's clothing?"

A middle-age client is caring for an older adult parent who has end-stage renal disease. Which statement by the client indicates to the nurse that the client is experiencing anticipatory loss?

"I am feeling so sad when I should be enjoying the time I have left with my parent."

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients."

A client is informed of the diagnosis of leukemia based on recent testing results. The client states, "I do not have leukemia." Which additional statement indicates the client is experiencing denial?

"Mistakes are made with laboratory tests all the time."

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone."

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

"The inability to talk about your dad without crying, even after a year, is still considered normal."

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."

The nurse is providing care for a client that is terminally ill with cancer. The client states to the nurse, "Am I going to die?" What is the most therapeutic response by the nurse?

"What have you been told?"

short but genuine grief reaction.

Abbreviated Grief

loss tangible to both the person sustaining the loss and to others.

Actual Loss

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning

Administer sedation and analgesia.

process of planning for future care in the event a person becomes unable to make his or her own decisions

Advance Care Planning (ACP)

written directive that allows people to state in advance what their choices for health care would be if certain circumstances should develop

Advance Directive

an order that no attempts are to be made to resuscitate a patient who stops breathing or whose heart stops beating

Allow Natural Death (AND) order

The nurse is caring for a client who has just expired. Which action will the nurse perform?

Allow the client's family to see the client's body before it is discharged.

condition in which a person displays loss and grief behaviors for a loss that has yet to take place

Anticipatory Loss

loss behaviors displayed before the actual loss occurs.

Anticipatory Loss

A client is dying and the nurse has developed a strong rapport with the client and spouse. The spouse states to the nurse, "I just don't know how I am going to deal with the process. It makes me nervous to think I can't deal with it." What is the priority concern with the spouse of the client?

Anxiety related to unknown reaction to stages of death

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible.

state of grieving or going through the grief process

Bereavement

The hospice nurse is caring for several clients on the unit. Which client is exhibiting signs or symptoms of impending death?

Client with circumoral cyanosis and abdominal mottling

an order written to indicate that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated

Comfort Measures Only order

The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply.

Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included. The nurse and health care provider are on call 24 hours, every day of the week.

(1) irreversible cessation of all functions of circulatory and respiratory functions; (2) irreversible cessation of all functions of the entire brain, including the brainstem; (3) termination of life

Death

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

an order specifying that there be no attempt to resuscitate a patient in the event of cardiopulmonary arrest

Do Not Resuscitate (DNR) order

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

Durable power of attorney form

abnormal or distorted grief that may be either unresolved or inhibited

Dysfunctional Grief

distorted or abnormal grief response, including inhibited grief (suppression of grief reaction) and unresolved grief (lengthy or denied grief reaction).

Dysfunctional Grief

mercy killing; the deliberate termination of the life of a person

Euthanasia

emotional response to loss

Grief

a type of end-of-life care for persons who are terminally ill, characterized by the following: (1) patients are kept as free of pain as possible so that they may die comfortably and with dignity; (2) patients receive continuity of care, are not abandoned, and do not lose personal identity; (3) patients retain as much control as possible over decisions regarding their care and are allowed to refuse further life-prolonging technologic interventions; and (4) patients are viewed as individuals with personal fears, thoughts, feelings, values, and hopes

Hospice Care

inaccessibility or change in a valued person, object, or situation.

Loss

stands for Medical Order for Life-Sustaining Treatment, a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis

MOLST form

stands for Physician Order for Life-Sustaining Treatment, a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis; must be completed and signed by a health care professional, not the patient

POLST form

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply

Pale, cool skin Decreased urine output Irregular heart rate

hospice care; taking care of the whole person—body, mind, spirit, heart, and soul—with the goal of giving patients with life-threatening illnesses the best quality of life they can have through the aggressive management of symptoms

Palliative Care

the lowering of patient consciousness with medication for the express purpose of limiting the patient's awareness of suffering that is intractable and intolerable

Palliative Sedation

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.

People vary widely in their responses to loss. Stages occur at varying rates among people. Some people actually skip some stages of grief altogether.

loss of youth, of financial independence, and of a valued environment experienced by a person, but intangible to others

Perceived Loss

loss tangible only to the person sustaining it.

Perceived Loss

loss of life, limb, an object, person, pet, or job.

Physical Loss

withdrawal of life-sustaining therapy with the understanding that death may result, generally after a decision is made that the therapy in question is medically futile or disproportionately burdensome

Terminal Weaning

loss that affects a person's self-image.

Psychological Loss

illness from which there is no reasonable expectation of recovery or cure

Terminal Illness

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.

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.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

The client's breathing becomes noisy.

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first.

The nurse is caring for a client with terminal illness. Which should the nurse teach the family about physiological signs of imminent death?

There will be changes in vital signs, skin color, and responsiveness.

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 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.

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 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.

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in?

adult

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms

The spouse of a recently deceased client states, "I just can't believe he left me. He swore he would never leave me and I feel betrayed!" Using Kübler-Ross stages of grief, what stage does the nurse identify the client is experiencing?

anger

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.

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

bereavement

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.

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

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.

The nurse is assessing a client recently diagnosed with terminal lung cancer who states, "This can't be happening to me. Maybe the doctor made a mistake." Which stage of death and dying is the client exhibiting?

denial

The nurse is taking care of a client recently involved in a motor vehicle accident during which a pet was thrown from the vehicle and died. The client states, "My heart aches and I can't eat or sleep." According to Kübler-Ross, what stage of grief is the client experiencing?

depression

A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

grief reaction

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

Actual Loss

loss that can be recognized by others as well as by the person sustaining the loss, such as loss of a limb or a spouse

Active Euthanasia

someone other than the patient commits an action with the intent to end the patient's life, for example, injecting the patient with a lethal dose of a drug